关键词: 分级诊疗, 系统评价, 动力与阻力, 上海市

Abstract: Objective　To assess the achievements and challenges of the implementation of hierarchical medical system （HMS） in Shanghai from a multi-stakeholder perspective based on a systematic review.Methods　The search was done in January 2018.We searched the databases of CBM，VIP，Wanfang Data Knowledge Service Platform，CNKI，PubMed，ScienceDirect and Ovid via Google Scholar，Baidu Scholar and other search engines to identify the articles about descriptive introduction and assessment of the implementation of HMS in Shanghai from their inception to January 10，2018.The data were synthesized with a thematic analysis approach with EPPI-Reviewer 3.0 software.Results　32 articles were included.Three themes emerged from the analysis：the level of satisfaction with the implementation of HMS，achievements of the implementation of HMS and challenges of the implementation of HMS.In terms of level of satisfaction with the implementation of HMS，healthcare providers（medical institutions，healthcare professionals and healthcare enterprises） showed high level of satisfaction while the healthcare receivers （residents/patients） and the organizer（the government） showed fair level of satisfaction with the implementation of HMS.With regard to the achievements of the implementation of HMS，medical institutions and healthcare professionals thought the rate of initial consultation in primary care and rate of signing a contract with the family doctor among residents were increasing，and healthcare cost and visits in primary care increased significantly，healthcare enterprises thought its implementation is conducive to the application and development of information technology；residents/patients considered that the implementation of HMS was beneficial to the delivery of convenient and inexpensive healthcare；the government put forward that the implementation of HMS played a role in diverting patients（although the effect of diverting was not obvious），and improved the equity and accessibility of healthcare and the efficiency of healthcare delivery.In respect of the challenges for the implementation of HMS，medical institutions and healthcare professionals pointed out that sharply increased visits overwhelmed the capabilities of primary care，residents thought the categories of drugs were inadequate in primary medical institutions，and they did not trust the service capabilities of primary care practices，and still preferred to go to large-scale hospitals when seeking healthcare，the government put forward that the supporting measures for the implementation of HMS were inadequate.Conclusion　The implementation of HMS in Shanghai needs to be improved further，which could be achieved by bettering and popularizing the HMS，raising the level of primary care quality，and improving the proportion of residents seeking healthcare in primary care.All these provide a reference for policy-making related to the development of HMS.

Key words: Hierarchical medical system, Systematic review, Power and resistance factors, Shanghai