Hard and soft medicine: Doctors’ framing and application of the disability category in their assessments of grant claimants’ fitness to work in South Africa
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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.