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Background Health system responsiveness is defined as the outcome of designing health facility relationships so that they are familiar and responsive to patients’ universally legitimate expectations. Even though different strategies have been implemented to measure responsiveness, only limited evidence exists in Sub-Saharan Africa. In Ethiopia, information about health system responsiveness among outpatients is limited. Assessing responsiveness could help facilities in improving service delivery based on patient expectations. Objective The study aimed to assess health system responsiveness and associated factors among outpatients in primary health care facilities, Asagirt District, Ethiopia, 2021. Methods Facility-based cross-sectional quantitative study was implemented between March 30 and April 30/2021. A systematic random sampling technique was employed to select 423 participants, and interviewer-administered data were collected using structured and pretested questionnaires. Both bivariable and multivariable logistic regressions were employed to identify factors associated with health system responsiveness. Adjusted Odds Ratio with their corresponding 95% CI was used to declare factors associated with health system responsiveness. A  p -value less than 0.05 was used to declare significant statistical variables. Results The overall health system responsiveness performance was 66.2% (95% CI: 61.4—70.7). Confidentiality and dignity were the highest responsive domains. Health system responsiveness was higher among satisfied patients (AOR: 9.9, 95% CI: 5.11–19.46), utilized private clinics (AOR: 8.8, 95% CI: 4.32–18.25), and no transport payment (AOR: 1.7, 95% CI: 1.03–2.92) in the study setting. Conclusion Overall, health system responsiveness performance was higher than a case-specific study in Ethiopia. To improve the health systems responsiveness and potentially fulfil patients’ legitimate expectations, we need to facilitate informed treatment choice, provide reasonable care within a reasonable time frame, and give patients the option of consulting a specialist. Aside from that, enhancing patient satisfaction, using input from service users, Collaboration, and exchanging experiences between public and private facilities will be important interventions to improve HSR performance.

Health system responsiveness and associated factors among outpatients in primary health care facilities in Ethiopia