Abstract: Background　China has issued a series of policies for the implementation of three-tiered healthcare system since the healthcare reform launched in 2009. However，there is still a big gap between the achievements obtained by more than ten years of efforts and the pre-defined goals. Hence，it is essential to make a systematic and quantitative analysis of the policies related to the system. Objective　To evaluate the force and effect of policies related to the implementation of three-tiered healthcare system in China. Methods　In September 2020，by using "iered diagnosis and treatment" "bi-directional referral" "initial treatment in primary care" as search terms，we searched databases of PKULAW.CN，Wanfang Data，and Baidu，and government websites for policies issued by the State Council and government ministries during 2009—2019，and enrolled 236 policy documents related to the implementation of three-tiered healthcare system after screening. Effectiveness can be divided into four dimensions：policy measures，policy objectives，policy feedback，and policy intensity. Effectiveness is expressed by the number of outpatient and emergency visits in primary medical and health institutions，and regression analysis is conducted on the implementation effects of hierarchical diagnosis and treatment of three different policy tools by constructing multiple regression models. Results　On the whole，change trends of the number and overall force of policies related to three-tiered healthcare system were basically the same over the 10 years，but the average force of the policies changed more insignificantly. The average scores for four evaluation dimensions，policy measures，objectives，feedback，and intensity were about 3.00（except 2013），less than 2.50（except 2019），2.25，less than 2.44 points，respectively. Three types of policies，supply-side，environmental，and demand-side showed the same change trend basically in terms of number，although the former two outnumbered the latter generally. Among the supply-side policies，those regarding the development of healthcare facilities occupied the largest proportion（36.67%），but the average force produced by those regarding funding or resource allocation was the largest（20.00）. Among the demand-side policies，those regarding medical insurance occupied the largest proportion（61.70%），and produced the largest force on average（15.07）. Of the environmental policies，those regarding objective planning accounted for the largest proportion（49.25%），and produced the largest force on average（20.25）. The regression coefficients for supply-side，demand-side and environmental policies were 1.271 9，2.013 8，and 1.937 8，respectively（P<0.10），with an effect lag ranging from 1-3 years. Conclusion　Our study indicates that the force and effect of policies related to three-tiered healthcare system may be owing to the cumulative effect of the number of policies. In terms of evaluation dimensions，policy measures were rated high on average，but the quantitative degree of policy objectives was low，the requirement for policy feedback was vague，and the policy intensity lacks promotion by high-level departments. Both supply-side and environmental policies basically outnumbered demand-side policies. The score of policy force and effect mainly depended on policy measures，especially supply-side and environmental policies. All these three types of policies have facilitated the promotion of tiered diagnosis and treatment in China，but demand-side policies may have the shortest effect lag and largest force and effect，so it is suggested that government departments should make efforts to fully use the effect of demand-side policies to guide residents to seek healthcare appropriately.

Key words: Hierarchical diagnosis and treatment, Health policy, Policy force, Policy effect

摘要： 背景　自新医改以来，我国制定了一系列分级诊疗政策，但十余年来，我国离全面实现分级诊疗的目标仍存在较大差距，因此，对国家出台的分级诊疗相关政策进行系统的量化分析显得尤为重要。目的　评估我国推动分级诊疗所发布的政策文件效力和实施效果。方法　2020年9月，在北大法宝、中国知网、万方数据知识服务平台、百度搜索引擎和政府部门相关网站等以“分级诊疗”“分级医疗”“双向转诊”“基层首诊”为检索词检索2009—2019年国家及各部委颁布的政策文件，经筛选后获得236项有助于分级诊疗制度推进的政策文件。效力分为政策措施、政策目标、政策反馈、政策力度4 个维度，效果用基层医疗卫生机构急诊就诊人次数指标表示，通过构建多元回归模型对三类不同政策工具分级诊疗实施效果进行回归分析。结果　2009—2019年的政策数量变化趋势与政策整体效力变化趋势基本一致，政策平均效力较平稳波动，政策措施得分在3.00分左右（除外2013年），政策目标得分均≤2.50分（除外2019年），政策反馈的平均得分在2.25分，政策力度平均得分<2.44分。供给、需求、环境型三类政策工具的政策数量变化趋势基本一致，供给型和环境型政策数量基本高于需求型政策。供给型政策中，医疗卫生机构建设类占比最多（36.67%），资金投入与资源分配类的平均效力值最高（20.00分）；需求型政策中，医保类最多（61.70%）且平均效力值最高（15.07分）；环境型政策中，目标规划类最多（49.25%）且平均效力值最高（20.25分）；供给型、需求型、环境型这三类政策工具对政策实施效果影响的回归系数分别为1.271 9、2.013 8和1.937 8（P均<0.10），滞后期在1~3年。结论　我国分级诊疗政策效力的提高主要得益于政策颁布数量的累计效应；4个评价维度中，政策措施平均得分较高，政策目标的量化度低，政策反馈要求模糊，政策力度缺乏高层级部门的推动；供给型和环境型政策的数量基本都高于需求型政策，政策效力的得分主要取决于政策措施，特别是供给型和环境型政策；三类政策工具均对我国分级诊疗的开展起到正向作用，且需求型政策无论从滞后期还是政策效果指向来看都最具优势。如何充分发挥需求型政策引导国民理性就医选择的促进作用，应引起政府部门的高度重视。

关键词: 分级诊疗, 卫生政策, 政策效力, 政策效果