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

摘要： 目的　系统评价上海市分级诊疗现状和面临的问题。方法　于2018年1月，采用计算机系统检索中国生物医学文献数据库（CBM）、维普网（VIP）、万方数据知识服务平台、中国知网、PubMed、ScienceDirect、Ovid及Google学术、百度学术等搜索引擎中与上海市分级诊疗的政策实施现状、效果及评价有关的文献。检索时间为各数据库建库至2018-01-10。采用EPPI-Reviewer 3.0软件，通过主题合成的方法进行定性资料的统计分析。结果　最终纳入32篇文献。医疗机构和医务人员（供方）对分级诊疗实施前后的效果满意度较高，认为基层首诊率和家庭医生签约率不断提升；医疗企业对分级诊疗实施前后的效果满意度较高，有利于提高信息技术在分级诊疗中的发展和应用；居民/患者（需方）对分级诊疗的实施效果满意度一般，就医行为仍然偏向大型医院；政府部门（组织方）对分级诊疗实施效果满意度一般，认为分级诊疗对于患者分流的效果不明显。研究共生成3项分析性主题，均包含动力因素和阻力因素两方面：（1）供方：动力包括基层医疗卫生机构就医费用、总诊疗人次增加，阻力包括患者数量激增，但医疗服务未得到同步改善等；（2）需方：动力包括分级诊疗可为居民提供方便、价廉的医疗服务，阻力包括基层医疗卫生机构药品欠缺、居民对基层医疗服务不信任等；（3）组织方：动力包括分级诊疗提高了卫生服务的公平性、可及性与效率，阻力包括分级诊疗配套措施不够细化等。结论　目前上海市分级诊疗还需要进一步完善，可通过提高基层医疗水平、完善分级诊疗制度、提高患者基层就医意愿、加大分级诊疗的宣传，深入推进分级诊疗的实施，为卫生决策提供理论参考。

关键词: 分级诊疗, 系统评价, 动力与阻力, 上海市