Browsing by Author "Kelly, Gabrielle"

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    Hard and soft medicine: Doctors’ framing and application of the disability category in their assessments of grant claimants’ fitness to work in South Africa
    (2016-07) Kelly, Gabrielle
    Using the framework of street-level bureaucracy theory, this paper examines the work of medical doctors in assessing eligibility for disability grants (DGs) in South Africa. Observations of doctor-patient encounters showed that, despite the state’s attempts to standardise disability assessment, significant variation remains in doctors’ decision-making. I argue that doctors’ divergence from rules and guidelines is driven by differences between the government’s bureaucratic framing of disability and the alternative frames used by doctors for making sense of cases and thinking about disability, illness and employability in the South African context. Doctors’ framing of DG cases was shaped by their social and cultural backgrounds and dispositions, their professional knowledge and values, and their broader discursive framings of rights and social justice. This paper makes an original empirical contribution to the study of conceptions of disability as a category of the ‘deserving’ poor in a context of high poverty. It also highlights the relationship and potential conflicts between professional expertise, social norms and values, and bureaucratic rules at the street-level, and shows how this shapes policy implementation and the ensuing ‘gap’ between policy and practice.
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    Regulating access to the disability grant in South Africa, 1990-2013
    (2013) Kelly, Gabrielle
    Disability is a universally difficult concept to define and assess for social assistance and social insurance purposes and these benefits have proven difficult to administer internationally because of ambiguities present in the process of determining the employability of people with physical impairments. In post-apartheid South Africa, disability grants (DGs) have proved especially difficult to regulate because of the added complexities of high levels of structural unemployment and poverty, an HIV epidemic and a social security system which does not cater adequately for all groups in need of support. The paper identifies three periods in the state's attempts to improve DG administration through legislative and regulatory measures since 1990: 1) a period of extending access and overcoming administrative barriers, supported by a socio-economic rights discourse; 2) a period of growth and generous access, resulting in growing concern about over-generosity and fiscal sustainability; 3) a period of action or 'rationalisation' in which the state places new limits on access to the grants, leading to decline in the number of social grant recipients. Common to all three periods are numerous and ongoing problems in the disability assessment process. These exist because disability is a complex, multi-dimensional concept, which is difficult and expensive to properly assess, especially in a context of high demand and significant resource limitations within the healthcare system.
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    “We want another doctor!” Citizen agency and contested notions of disability in social assistance applications in South Africa
    (2016-07) Kelly, Gabrielle
    Problems in fairly allocating welfare and health resources or targeting social programmes are very often located in the spaces where citizens interact directly with state workers. This study draws on observations of doctor-patient encounters in disability assessments for the South African disability grant (DG), to examine how doctor-patient interactions shape social welfare allocation. I show that interactions between doctors and patients are sites of negotiation and contestation over rights to social assistance. Claimants’ understanding of disability differed from biomedical conceptions of disability. Doctors carrying out DG assessments faced both direct and indirect pressure from claimants, who aimed to influence their decisions through narratives of suffering and performances of disability. Frustrated by communication barriers, as well as the perceived unfairness and arbitrary nature of assessments, some claimants used verbal or physical abuse as a form of protest against the system. In order to defend themselves from these pressures and maintain authority in these interactions, doctors employed coping strategies that distanced and objectified claimants, minimising opportunities for patients to bully them or affect their judgment. These strategies strained already tense doctor-patient relationships and made the DG system illegible to the public. This demonstrates the importance of considering trust, power dynamics and the exercise of agency by both patients and providers in understanding policy implementation.