Is the health system working for people? Comparison of adolescent and adult perspectives from the people´s voice survey in Germany

BACKGROUND: People-centred health system performance assessments rely largely on adults, with limited inclusion of adolescents despite their distinct health needs and rights to participate in decisions concerning their health. The People's Voice Survey is a multi-country, adult-population-representative survey of health system perceptions, but it includes adolescents in the German survey. Germany's health system offers financial protection and commits to adolescent participation, yet little is known about adolescents' views of its performance. We aimed to identify adolescent-specific experiences and perspectives by comparing adolescents' and adults' experiences and perceptions of health system performance. METHODS: Population-representative data were collected through an online panel between December 2024 and January 2025. Respondents could choose to take the survey in either German or English. Because adolescents were intentionally oversampled to enable age-group comparisons, we conducted a weighted cross-sectional analysis comparing adolescents (15-19 years) with adults (≥ 20 years) using descriptive statistics and chi-square tests. Variables included self-reported health status, confidence and autonomy in managing health, experiences during care delivery, and perceptions of the health system. Weighted descriptive analyses and chi-square tests were performed. RESULTS: The total sample included 2,698 participants: 257 adolescents and 2,441 adults. Compared with adults, adolescents reported better physical but poorer mental health, lower confidence and autonomy in making their own health decisions and communicating concerns to healthcare providers. Compared with adults, adolescents more frequently perceived medical mistakes and receiving care without feeling sufficiently informed, and reported higher levels of unfair or discriminatory treatment. Adults were more critical of the changes to the health system in the past two years and of the system's overall performance. Despite adolescents' poorer experiences, they had a more positive outlook on the health system's performance. CONCLUSIONS: Our findings underscore the need to support adolescents' autonomy in making their own health-related decisions and participating in healthcare through age-appropriate communication and opportunities for independent consultations. They also highlight the importance of directly including adolescents in health system performance monitoring, as relying primarily on adult populations may overlook adolescents' unique healthcare experiences and unmet needs.