measuring performance of health systems is an essential tool for health policy - makers to conduct analysis and track change . the 2000world health organization ( who ) report reflects that promoting health status , fairness in financing and responsiveness are the three main goals of evaluating health system performances ( 2 ) . responsiveness refers to the ability of a health system to respond to the legitimate expectations of the population ; this is associated with the non - medical aspect of the health system and environment in which the people are treated ( 2,3 ) . " respect for human right " and " client - orientation " are two broad categories of responsiveness . furthermore , respect for human right consists of dignity , autonomy , communication and confidentiality ( 2,4 ) . client orientation includes prompt attention , quality of basic amenities and access to social support networks as well as choice of provider . in 2000 , iran s health system was ranked 100th in terms of responsiveness ( 2,5 ) . prompt attention and dignity were the most important domains of responsiveness of health systems for the iranian populations ( 6 ) . besides , urgent and special attention was recommended to improve the responsiveness of the health system ( 7,8 ) . 
 
 in a survey on health system responsiveness in tehran , more than 90% of the households believed that responsiveness was very important ( 5 ) . in addition , it was reported that responsiveness was better for outpatient care than inpatient care ( 9 ) . most of the studies on health care responsiveness have focused on household survey , and only a few studies were conducted to address the responsiveness of a health system to inpatient care ( 5,6,10,11 ) . moreover , there is a gap in the concerning patients views on health system responsiveness in iran . the 11th government , elected in june 2013 , took health as the top priority of its administration and has been implementing a health sector evolution plan ( hsep ) since may 6 , 2014 ( 12 ) . hsep is a national plan , with two main phases : the first phase relating to improving fair access to healthcare and quality of inpatient and outpatient care in hospitals and the second to the public health care ( 13 ) . hsep aimed to provide the followings : health insurance coverage to all uninsured individuals , reducing out - of - pocket expenses for inpatient services , providing financial protection of patients with specific diseases and poor patients , encouraging medical doctors to stay in deprived areas through motivational policies , improving quality of care through increasing specialists , and improving hospital amenities and lodging services ( 13,8 ) . this study aimed at examining the effect of hsep on health system responsiveness in kermanshah , western iran . the findings may contribute to improvements in the responsiveness of the health system in this area of iran . this was a cross - sectional study conducted on the responsiveness of the hospitals in admitted patients in kermanshah in 2015 . the city has seven public university hospitals with a total number of 1,570 active beds and two private hospitals . data were collected from six public university hospitals with the exception of the seventh university hospital , which was a psychiatry hospital . a sample of 335 patients was calculated using the formula for single population proportion at 50% proportion of responsiveness ( as no evidence was available from similar studies in the area ) , 5% level of significance and 0.05 margin of error . the proportionate allocation to population size technique was employed to collect data from each hospital . at least three days hospitalization by a patient and age above three years were the inclusion criteria whilst patients who refused to participate or admission in intensive or critical care units were excluded . data were collected using standard world health survey(whs ) questionnaire , which was developed by world health organization ( who).this questionnaire is a valid , reliable and comparative instrument that contains questions about the  importance of responsiveness domains from an inpatient s point of view ,  health services utilization and  people 's view about the responsiveness domain of inpatient services ( 14 ) . items in each component of responsiveness were as follows : prompt attention ( 2 items ) ; communication ( 2 items ) ; human gentility and dignity ( 2 items ) ; patient s participation in decision - making and autonomy ( 2 items ) ; confidentiality and trust ( 2 items ) ; choice of provider ( 1 items ) ; quality of basic amenities ( 2 items ) ; and access to social support ( 2 items ) . in this study , responsiveness of the hospitals was considered as a dependent variable while the socio - demographic variables of the patients were the independent variables . we used a five - point likert scale where 5was very important / very good , and 1 represented least important / very poor . the responsiveness score for each domain was obtained by dividing the sum of the scores within the domain by the number of items in the likert scale . the stata version 12 statistical package was used to analyze the responses of a five - point likert scale data . the frequency distribution , ranges and mean ( sd ) were used to describe the data . the principal component analysis ( pca ) similar to another study in iran ( 5 ) , we used 0.4 and above as a cutoff for factor loading in the pca . the overall relationship between the socio - demographic variables and health system responsiveness was checked by chi - square test . this was a cross - sectional study conducted on the responsiveness of the hospitals in admitted patients in kermanshah in 2015 . the city has seven public university hospitals with a total number of 1,570 active beds and two private hospitals . data were collected from six public university hospitals with the exception of the seventh university hospital , which was a psychiatry hospital . a sample of 335 patients was calculated using the formula for single population proportion at 50% proportion of responsiveness ( as no evidence was available from similar studies in the area ) , 5% level of significance and 0.05 margin of error . the proportionate allocation to population size technique was employed to collect data from each hospital . at least three days hospitalization by a patient and age above three years were the inclusion criteria whilst patients who refused to participate or admission in intensive or critical care units were excluded . data were collected using standard world health survey(whs ) questionnaire , which was developed by world health organization ( who).this questionnaire is a valid , reliable and comparative instrument that contains questions about the  importance of responsiveness domains from an inpatient s point of view ,  health services utilization and  people 's view about the responsiveness domain of inpatient services ( 14 ) . items in each component of responsiveness were as follows : prompt attention ( 2 items ) ; communication ( 2 items ) ; human gentility and dignity ( 2 items ) ; patient s participation in decision - making and autonomy ( 2 items ) ; confidentiality and trust ( 2 items ) ; choice of provider ( 1 items ) ; quality of basic amenities ( 2 items ) ; and access to social support ( 2 items ) . in this study , responsiveness of the hospitals was considered as a dependent variable while the socio - demographic variables of the patients were the independent variables . we used a five - point likert scale where 5was very important / very good , and 1 represented least important / very poor . the responsiveness score for each domain was obtained by dividing the sum of the scores within the domain by the number of items in the likert scale . the stata version 12 statistical package was used to analyze the responses of a five - point likert scale data . the frequency distribution , ranges and mean ( sd ) were used to describe the data . the principal component analysis ( pca ) similar to another study in iran ( 5 ) , we used 0.4 and above as a cutoff for factor loading in the pca . the overall relationship between the socio - demographic variables and health system responsiveness was checked by chi - square test . three hundred thirty five , 190 ( 56.7% ) male and 145 ( 43.3% ) female , patients with the mean ( sd ) age of 41.5 ( 2.36 ) yrs . and the age range of 3 - 92 yrs.were included in the study . of the respondents , 92.8% had health insurance coverage , and 44.7 % were illiterate ( table 1 ) . 
 
 the respondents rank on the level of importance of the health system responsiveness based on the domains of the responsiveness questionnaire is shown in fig . the proportion of patients who rated the responsiveness of the hospitals as important or very important based on quality of the basic amenities , communication and dignity domains accounted for 94% , 91% and 90% , respectively . the social support domain was considered as the least domain as only 77% of the patients rated this domain as important or very important . proportion of the participants who rated the responsiveness domain as important / very important 
 the mean performance of each domain of the health system responsiveness is shown in table 2 . the best and worst performance for domains of dignity and autonomy were 82.2 and 62.5 , respectively . the findings indicated that 68% of the variance of the overall responsiveness score was explained by four components . the first component which contained communication , dignity and autonomy explained 31.4% of the variance ; the second component contained confidently and social support and explained17.6 % of the variance ; the third component contained quality of basic amenities and choice domain and explained 11% of the variance and the fourth component contained dignity domain only and explained8% of the variance . the empirical analysis revealed no significant association between total health system responsiveness scores and gender , education , age , health insurance coverage , and working status of the respondents . this study was the first of its type after health sector evolution plan ( hsep ) . the aim of this study was to describe health system responsiveness in western part of iran . however , several studies have been conducted on health system responsiveness before hsep elsewhere ( 5,10,11,16 ) . responsiveness of the health system is the result of interactions between health system agents and the patients ( 16 ) , which is related to the patient s well - being ( 17 ) . the well - being of the patients is influenced by health system and the health system s responsiveness to the patients ( 18 ) . quality of basic amenities , dignity , communication and prompt attention received higher scores in terms of importance . this implies that from patient s point of view , these domains are more important than other domains of responsiveness . in addition , compared to previous studies in iran , patients kept their preferences about responsiveness domains . 
 
 in this study , the mean performance of each domain of the health system responsiveness was not much different except for autonomy that was rated the least . in another study that assessed the responsiveness of hospitals to inpatient care in zanjan reported an overall responsiveness score of 58.4 ( 10 ) . similarly , karami - tanha et al . found hospital responsiveness score of 57 to patients with heart failure ( 15 ) . furthermore , a household survey on responsiveness of health systems to outpatient and inpatient services in tehran reported 70.6 responsiveness score ( 5 ) . generally , the overall score of responsiveness of the hospitals to inpatient services in our study was higher than the scores reported in previous studies in iran . besides , hospital responsiveness scores in our study were higher than the scores reported in studies elsewhere ( 9,21,22 ) , but lower than the scores reported in germany ( 23 ) . 
 
 in this study , dignity , confidentiality , and quality of basic amenities had the best performance . this finding is in line with the reports of several studies ( 11,15,17,18 ) , and with that of rashidian et al . , but the quality of basic amenities in their report was the second worst performance ( 5 ) . in  previous  iranian studies , social support / confidentiality/ dignity ( 11 ) , dignity/ confidentiality/ prompt attention/ ( 5 ) , dignity/ confidentiality/ prompt attention ( 15 ) confidentiality/ communication / prompt attention ( 10 ) were reported as the best performing domains . unlike our study , a study in china reported social support to be the best performance domain ( 24 ) . confidentiality and dignity domains achieved highest scores in the health system of iran before and after hsep . in addition , a high score in the quality of basic amenities means that the rooms in the hospitals were clean and there were enough waiting and examination rooms . in fact , after hsep , public hospital rooms were renovated and lodging and welfare equipment were purchased ( 12 ) . in this study , the autonomy domain had the worst performance score followed by choice domain . this finding is similar to the findings reported in several other studies ( 5,10,15,22,23 ) . in the above - mentioned study of iran , autonomy/ quality of basic amenities ( 5 ) , autonomy/ communication ( 11 ) , choice/ autonomy ( 10 ) , and autonomy / choice received the least score ( 15 ) . in this study , performance of hospitals with respect to communication , prompt attention , social support , choice and autonomy were rated 4th to 8 , respectively . therefore , providing training for the health care providers and improving their knowledge is necessary to achieve a higher score in the autonomy and choice domains . 
 
 in this study , the principal component analysis revealed that responsiveness for inpatients care included communication dignity/ autonomy , confidently/ social support , and lastly quality of basic amenities / choice as the main factors . in a study conducted in taiwan , five factors of respect , access , confidentiality , basic amenities and social support were extracted . these five factors revealed acceptable internal consistency , four of which were significantly correlated with the overall responsiveness score ( 25).in other studies , communication , autonomy and confidentiality were the main factors ( 5,21 ) . while the majority of the above - mentioned reports included both inpatient and outpatient cares , this study was limited to inpatient care and university hospitals . this study indicated a high rate of overall responsiveness score of each of the domains compared to other similar previous studies in iran . although it is difficult to reach a conclusion , our findings may show better responsiveness of the health system than the previous reports . the relatively higher responsiveness of the hospitals in the " quality of basic amenities " domain may be a direct result of huge resources use that was allocated to the hospitals during hsep . finally , improvement in  client - oriented  domains of health system responsiveness such as quality of basic amenities and prompt attention may require large investments and additional resources , while improvement in
background : responsiveness is one of the three main goals of the health system introduced by world health 
 organization . 
 this study aimed at examining health system responsiveness after health sector evolution plan in 
 kermanshah , western iran . 
 methods : a sample of 335 hospitalized patients was selected using proportionate allocation to population size 
 method in the city of kermanshah ( iran ) in 2015 . 
 world health survey ( whs ) questionnaire was used to collect 
 data . 
 data were analyzed using descriptive statistics and principal component analysis by stata 12 . 
 results : the overall health system responsiveness score was 72.6 . 
 the best and worst performance for domains 
 of dignity and autonomy were 82.2 and 62.5 , respectively . 
 socio - demographic variables of the patients 
 had no significant effect on the total health system responsiveness score . 
 the principal component analysis findings 
 indicated that 68% of the variance of the overall responsiveness score was explained by four components . 
 conclusion : the overall responsiveness score of each of the domains was higher than that of other similar 
 previous studies in iran . although it is difficult to reach a conclusion , our findings may show better responsiveness 
 of the health system compared to the previous reports