Purpose Pay-for-performance (P4P) as an innovation for improved health care has been introduced in many health systems worldwide. The aim of this article is to apply and refine a specific theoretical angle for the analysis of these reforms, the theoretical frameworks of public policy instruments and programmatic actors, in order to highlight differences between countries. Design/methodology/approach This analysis is based on a comparative case study of the introduction of P4P in France and Germany in the ambulatory sector for the period from 2007 until 2017. This included a literature review and semi-structured interviews with 23 actors between 2013 and 2015. Findings The introduction of a supposedly clear-cut policy instrument – P4P in health care – is distinctly shaped by the intertwined configuration of institutional architecture and the policy programme of key system actors. This can be understood as a continuation of long-term transformations, most importantly the increasingly direct influence of the state and a weakening of the representation of the medical profession, as well as an internal fragmentation of the latter. Originality/value This analysis illustrates the applicability of the policy instrument approach to the heath sector. In addition, the authors have applied the dual perspective of policy instruments and programmatic actors. Both proved complementary and appropriate for the study of a highly technical instrument such as P4P.