This health millennium development goals (MDGs) program for results (PforR) operation contributes to Ethiopia's fourth health sector development program (HSDP-IV) objectives by disbursing against achievement of a subset of its key results. MDG performance fund (PF) supports a sub set of key priorities for HSDP-IV. The three areas that the MDG PF supports are: (i) maternal health, (ii) child health, and (iii) strengthening health systems. The presented P4R operation will provide 100 million dollars International Development Association (IDA) funding for the MDG PF provided agreed results have been achieved and have been verified. The IDA credit will be complemented by a United States (U.S.) 20 million dollars grant under the health results innovation trust fund (HRITF). The assessment examined program expenditure framework to determine whether it is comprehensive, clearly defined, and determination whether it is part of the borrower's budget and financial management processes. It also focused on key elements of program procurement arrangements. The key risks identified by the integrated fiduciary systems assessment arise from the performance of the pharmaceutical fund and supply agency (PFSA), which is critical for PforR operation, and responsible for procuring and distributing most of the health products required for producing the results. The assessment concludes that the examined program financial management and procurement systems are adequate to provide reasonable assurance that the financing proceeds will be used for intended purposes, with due attention to principles of economy, efficiency, effectiveness, transparency, and accountability and for safeguarding program assets.