Examines the experience of countries with and without MTEFs over the period 1990 to 2008. It does so by adopting a systematic methodological approach and relying on multiple analytical techniques to obtain results about the impact of MTEFs. It draws on case study material to determine whether MTEFs should be a common element of PFM systems given differences in country circumstances; and provide some guidance on the design and implementation of MTEFs in the context of broader PFM reform.