Germany’s plans to tighten sick-note rules may be mistaking the symptoms of rising absenteeism for the underlying illness, researchers say, pointing to mental health strains and deteriorating working conditions in sectors such as healthcare and education.
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.
Under plans agreed by Chancellor Friedrich Merz’s coalition, telephone sick notes would be scrapped and employers could require medical certificates from the first day of absence, part of a broader push to raise productivity in an economy grappling with an ageing population and years of weak growth.
But 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 is 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 shows.
“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.
“They have jobs with high responsibility, they need to combine task performance and social interaction and they have to deal with emotional problems, but also with physical stressors, including violence,” Siegrist said. “And often these are low-paid people with a rather low socioeconomic status.”
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.
Recent evidence from Germany’s schools illustrates the problem. The 2024 German School Barometer found that nearly half of teachers reported psychological or physical violence among pupils at their school, while more than one-third felt emotionally exhausted several times a week.
Nursing tells a similar story. Despite acute staff shortages, recent German studies have found surprisingly limited wage increases, particularly in hospitals and public institutions.
The health ministry declined to comment when asked about absenteeism rates being highest in sectors with the biggest mental health and emotional pressures.
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.
“What we can say is that sick leave rules are one factor among many, and we would caution against reading too much into direct country comparisons of sick leave rates,” said OECD researcher Sofia Malinai Domagk.
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 number of sick days has since stabilised.
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.
“The available scientific studies suggest that sick leave by phone has not led to an increase in sick leave reports,” said Enzo Weber, from the Institute of Employment Research.
BEYOND POLICING ABSENCE
The government’s proposal has also 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.
(Reporting by Francesco Canepa and Maria Martinez)
