Illness: how the rules and protections are changing in Europe – who pays and for how long

The picture is very mixed. Whilst in some countries the first few days of sick leave are unpaid to discourage abuse, in others financial support kicks in immediately. Differences are also evident when it comes to bureaucracy: alongside fully digitalised systems, procedures requiring certificates, authorisations and repeated visits still persist. Here is an overview of the main rules in force in some European countries.

In Romania, from February 2025, the first day of sick leave will no longer be paid. The government has justified this decision on the grounds of the need to tackle what it considers to be fraudulent absences. Following protests and public debate, Parliament intervened by introducing certain exceptions: hospitalised patients, medical emergencies and people suffering from serious chronic conditions will continue to receive sick pay from the first day. For all other workers, however, the pay cut on the first day of absence remains in place.

The Romanian system is characterised by a high degree of bureaucracy. To obtain a sick note, the employee must present the doctor with a statement from their employer confirming that health insurance contributions have been paid and stating the number of sick days already taken in the current year. It is also necessary to present the health card and validate it in the computer system. The state, in fact, does not have a single database containing this information.

Managing long-term absences also involves a number of steps. The GP may grant a maximum of seven days’ sick leave for the same condition; for longer periods, the employee must undergo a specialist examination and obtain a new authorisation. The standard limit is 183 days per year, although exceptions are made for serious conditions such as cancer and tuberculosis.

In France, the system includes a waiting period during which the employee receives no benefits for the first few days of absence. Social security benefits begin after three days, whilst any supplementary benefits provided by the employer generally come into effect after seven days, unless more favourable terms are provided for in collective agreements.

The administrative procedure is relatively straightforward: the doctor issues the certificate and the employee sends it to their employer. Absences can be covered for up to six months and, provided there is adequate medical documentation, for even longer periods.

In recent years, the issue of sick leave has become a key topic of public debate. According to a study by Axa, the number of sick days has risen by 50% compared to 2019. The government has announced more thorough checks, particularly on absences lasting longer than a month, to verify consistency between diagnoses, treatment plans and medical prescriptions.

In Austria, employers may request a medical certificate from the very first day of absence, although many collective agreements stipulate that this is only required from the fourth day onwards. During sick leave, the employee initially continues to receive their full salary; thereafter, the health insurance system takes over and can provide financial support for up to 26 weeks, extendable in some cases to 78 weeks.

Obtaining the certificate is considered relatively straightforward, but the procedures become more complex in the case of long-term absences, when the cost is gradually transferred from the employer to the social security system.

In 2024, a wide-ranging public debate began on the possibility of making the first day of sick leave unpaid. The proposal, backed by some business organisations, was opposed by the trade unions and the Chamber of Labour, which highlighted the risk of encouraging employees to work even when they are ill. However, the debate did not result in any legislative changes.

Lithuania’s system is one of the most digitised. There are no waiting days: the employer pays for the first two days of absence, whilst from the third day onwards the public fund Sodra steps in. Sick notes are entirely electronic and are automatically sent to both the employer and the social security authorities.

There is no strict annual limit, but absences exceeding 122 consecutive days trigger a long-term assessment of the worker’s ability to work. To prevent any abuse, the social security system may require the worker to undergo a second medical assessment.

In Spain, the first three days of sick leave for common illnesses are unpaid, unless collective agreements provide for additional payments. From the fourth to the twentieth day, 60% of the basic pay is paid, a percentage that rises to 75% from the twenty-first day onwards. For accidents at work and occupational illnesses, however, sick pay begins immediately.

The procedure is almost entirely digital: the certificate is sent directly by the doctor to the social security authorities and the employer. The standard maximum duration of sick leave is 545 days, which may be extended in special cases to up to 730 days.

In 2025, the country recorded a new record for sick leave. Particularly significant is the rise in absences attributable to mental health issues, which have overtaken musculoskeletal conditions as the second leading cause of absenteeism. Businesses and trade unions are divided over the causes: the former are calling for stricter controls, whilst the latter are drawing attention to the deterioration of the healthcare system and the ageing of the working population.

In Bulgaria, insured workers receive a benefit equivalent to 80% of their gross pay whilst on sick leave, rising to 90% in the event of an accident at work or an occupational illness. To be eligible for this benefit, it is generally necessary to have made contributions for at least six months.

According to figures from 2025, expenditure on sick pay reached almost €550 million, equivalent to around 0.5% of national GDP. Absences affected 965,000 workers and covered over 16.7 million working days. The most common conditions were viral infections and respiratory illnesses.

In Poland, every day of sick leave is paid. The first 33 days are paid by the employer, after which the social security institution ZUS takes over. The benefit amounts to 80% of the average pay over the last twelve months and can be paid for up to a maximum of 182 days a year.

Since 2018, the entire process has been digitised: doctors now send the certificate directly to the social security agency. However, checks to prevent fraud remain very frequent. In the first quarter of last year, 227,000 checks were carried out, leading to the suspension of almost 15,000 benefits.

However, since 2025, the rules have been relaxed, allowing workers on sick leave to carry out normal daily activities, such as going shopping or taking their children to school, without automatically losing their entitlement to sick pay.

In Greece, the system provides for a three-day waiting period during which the employer pays only half of the daily wage. After that, the social security body EFKA takes over. The maximum duration of benefits varies depending on the individual’s contribution history and can be up to 720 days in the most complex cases.

The main problem is the bureaucracy: to obtain certification, a private doctor’s opinion is not sufficient; instead, you must consult doctors registered with EFKA, which often involves long waiting times.

*This article is part of the project by European collaborative journalism project “Pulse”and was produced with contributions from Alina Neagu (HotNews, Romania), Francesca de Benedetti (Voxeurop, France), Natascha Ickert (Der Standard, Austria), Krasen Nikolov (Mediapool, Bulgaria), Ana Somavilla (El Confidencial, Spain), Lena Kyriakidi (EfSyn, Greece) and Emilia Bromber (Gazeta Wyborcza, Poland).