Background Performance-based financing (PBF) has attracted considerable attention in recent years in low and middle-income countries. Afghanistan’s Ministry of Public Health (MoPH) implemented a PBF programme between 2010 and 2015 to strengthen the utilisation of maternal and child health services in primary health facilities. Methods We used a political economy analysis framework which aims to understand the main dynamics that influence the adoption and design of a policy and facilitates the exploration of policy processes and the roles played by key actors at various stages of implementation. Retrospective qualitative research methods were employed. The data comprised transcripts of key informant interviews and a review of PBF related documents. Results This study discovered a range of contextual factors contributing to the introduction of PBF in Afghanistan. In addition, the study identified the role, power, interest, and ideas of actors in relation to PBF and the extent to which they were involved in and affected the design, adoption, and implementation of PBF programme in the country. Besides, the study described the process of PBF programme design and how it was implemented in practice, including nonconformities to the initial design and reasons for these. Discussion Political economy factors played a critical role in the introduction, design and implementation of PBF programme in Afghanistan. This study highlighted a number of contextual factors including global and local forces supporting the introduction of PBF in Afghanistan. The process underlying the design and implementation of the PBF programme was a result of power and resource dynamics between PBF programme actors. This study makes an important contribution to the global literature through its focus on a low-income setting and a fragile and conflict-affected state where numerous forces have combined to bring a programme into existence and have influenced its implementation and outcome. Conclusion PBF programmes are inherently political as they enforce distinct arrangements for the sharing of resources and represents a risk or opportunity to actors as a result of changes to their roles and responsibilities and the modification of organisational processes. Future studies are required to focus on conducting empirical research to understand the main political economy dynamics that influence the policy cycle of such programmes. We recommend further use of political economy analysis in such studies.

The authors have withdrawn this preprint due to erroneous posting.