Introduction: Linking payments to results is introduced as a mechanism for increasing accountability. To this end, a policy, called IR-PfP, was implemented in Iran in 2014 as one of the components of the country's Health Transformation Plan. Thus, the present study aimed to report on the steps of agenda setting, development and implementation of this policy.Methodology: The present qualitative study was conducted in 2018 through document analysis and interviews. As for data analysis, the

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... analysis method with a theory-based approach and MAXQDA10 software were applied.Findings: The results indicated that the Refined Multiple Streams Framework well described the implementation of the policy. The three streams of law enforcement (Politics), shortcomings of the ongoing program (NPS) (Problem) and Pay for Performance mechanism (Policy) were merged with the opening of the first opportunity window, and the second opportunity window led to the incorporation of the next five streams. Therefore, the policy stream was redefined, and the politics and problem streams were respectively strengthened by some events, which were the dominant streams. The program and process streams became very weak due to executive and time limitations.Conclusion: The policy stream followed the politics and problem streams. The multiplicity of opportunity windows was verified, and creation of an institution and two policy groups were the main factors in agenda setting. The combination of all these results, stress the importance of dynamic studying of Iran's health policies.