Germany’s plans to tighten sick-note rules have been slammed by unions and doctors’ associations, which suggest that the rise in sick days, among the highest in the world, may be linked to mental health strains and deteriorating working conditions in sectors likes healthcare and education.
Reuters reports that workers in Germany took an average of about 22 days of sick leave in 2024, among the highest levels internationally.
That figure, from the association of company health insurers BKK, jumped sharply in 2022 after the introduction of electronic sick-note reporting, which improved the recording of short-term absences.
But government proposals that may be effective from January next year mean that workers will now no longer be able to get a sick note over the phone. They must visit a doctor in person, and from the first day of illness, will require medical certificates as part of a broader push to raise productivity in an economy grappling with an ageing population and years of weak growth.
However, workers’ unions have criticised the proposals, as have doctors.
And researchers studying sickness, mental health and labour markets increasingly point to deeper problems in professions where absenteeism is high, such as nursing, care work and teaching.
They cite chronic understaffing, low pay, weak career prospects and high emotional demands as risk factors for poor mental health in those professions.
In 2024, the latest year for which sectoral data are available, women in healthcare and social work took on average 27 sick days and teachers took 24, compared with 18 in finance and 16 in communication, BKK data show.
“It doesn’t need to be a full-blown depression,” said Johannes Siegrist, an emeritus Professor at the University of Duesseldorf. “It can also be a state of exhaustion or burnout as a result of problematic working conditions.”
Mental disorders account for only 4.8% of sickness cases, but when they occur they lead to 28 days of absence on average, according to data from AOK, Germany’s largest health insurance provider.
The number of sickness leave days taken by AOK members due to mental health issues has risen by 47% since 2014, making it the second-biggest cause of absence after respiratory diseases.
High responsibility, low reward
Healthcare, education and social services tend to have the highest proportion of mental health-related diagnoses.
The combination of low pay, social status or security with high demands is what scholars describe as an effort-reward imbalance.
A large body of international occupational health research has linked this imbalance to mental health issues and long-term absence. It also increases the risk of coronary heart disease.
No sign of widespread abuse
None of this means Germany’s absenteeism problem can be explained solely by mental health.
Sickness absence is influenced by a range of factors, including demographics, workplace conditions, social norms and institutional differences, making international comparisons difficult.
Germany’s sick-pay arrangements, which replace 100% of wages from the first day of illness, for up to six weeks, are some of the most generous in the world.
Yet seven OECD countries – Norway, Slovenia, Spain, Finland, France, Portugal and Belgium – report a higher incidence of sick leave among full-time employees.
Many of the institutions studying Germany’s absenteeism surge have struggled to find evidence of widespread abuse.
A study by health insurer DAK and the IGES Institute found that the sharp increase in recorded absences in 2022 was driven largely by better electronic reporting and unusually strong waves of respiratory illness and Covid infections. The study found no evidence that telephone sick notes introduced in 2020 during the pandemic were responsible for the surge and concluded that neither telephone certification nor routine malingering explained record sickness levels.
Beyond policing absence
The government’s proposal has been criticised by the services union Verdi, which said it exemplified a “culture of mistrust” towards workers.
Doctors’ associations said it would be “absolutely disastrous” for already overburdened medical practices.
In response, the government said companies will have the freedom to decide whether they want to follow the new rule or to retain the requirement to provide a medical certificate from the fourth day of illness.
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