Much of the existing empirical literature on the association between health insurance and out-of-pocket (OOP) expenditures on facility-based delivery in low- and middle-income countries is cross sectional in nature. Comparatively little is known about the dynamic shifts in OOP expenditures and the health insurance nexus. Using seven biennial waves of Vietnam’s Household Living Standard Survey covering the period 2006–2018 and a generalized linear model this study examines trends in OOP expenditures on facility-based delivery and financial protection afforded by Vietnam’s social health insurance system. Over the period under consideration, the pattern of health facility utilization among the insured shifted steadily from commune health centers towards higher-level government hospitals. Real OOP for delivery was 52.7% higher in 2018 than in 2006–2008 and insurance reduced OOP expenditures by 28.5%. Compared to district hospitals, giving birth at higher-level government hospitals increased OOP expenditures by 72.3% while giving birth at commune health centers reduced OOP expenditures by 55.7%. Additional analysis involving interactions between insurance status, types of public health facility and year dummies suggested a drop in financial protection of insurance, from 48% to 26.9% among women delivering at district hospitals and from 31.2 to 18.7% among those delivering at higher-level government hospitals. The modest financial protection of health insurance and its declining trend calls for policy measures that would strengthen the quality of maternal care at primary care institutions, strengthen financial protection and curb the provision of two-tiered clinical services and charges.

现有的关于健康保险与低收入和中等收入国家基于设施的自付费用 (OOP) 支出之间关联的实证文献大多是横断面的。对于自费支出的动态变化和健康保险关系，人们知之甚少。本研究使用涵盖 2006 年至 2018 年期间的越南家庭生活水平调查的七次两年期和广义线性模型，研究了越南社会医疗保险系统提供的基于设施的交付和财务保护的自营支出趋势。在研究期间，被保险人的医疗设施使用模式稳步从社区卫生中心转向更高级别的政府医院。交付的实际 OOP 为 52。2018 年比 2006-2008 年高出 7%，而保险将 OOP 支出减少了 28.5%。与区级医院相比，在上级政府医院分娩增加了 72.3% 的自费支出，而在公社卫生院分娩则减少了 55.7% 的自费支出。涉及保险状况、公共卫生设施类型和年度虚拟变量之间相互作用的额外分析表明，在地区医院分娩的女性中，保险的财务保护从 48% 下降到 26.9%，在更高级别分娩的女性中从 31.2% 下降到 18.7%政府医院。健康保险的适度财务保护及其下降趋势要求采取政策措施来提高初级保健机构的孕产妇保健质量，