Ways of Coping: how medical doctors manage their work within the social security system in South Africa
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Healthcare professionals in South Africa face significant challenges working in the overburdened and poorly resourced public healthcare system. Using the framework of street-level bureaucracy theory, this paper explores the coping strategies that medical doctors use in the context of conducting disability assessments for the South African disability grant (DG). Based on observations of medical assessment practice, as well as interviews with medical doctors, findings showed that doctors felt marginalised by the DG system and unsupported in carrying out their work. Many were overwhelmed by large patient numbers; faced significant professional and moral conflicts in carrying out assessments; and struggled with the interpersonal aspects of assessments, particularly pressure from patients to recommend grants. Using their discretion, doctors took short-cuts in their practice and employed coping strategies to simplify, and manage the conflicts and emotional stress of their work. These practices led to poor service standards and inconsistent decision-making. Some coping strategies involved objectifying and distancing claimants, which damaged patient trust in doctors and in the health and social security system more broadly. In outlining these coping strategies and their effects on policy implementation, this paper demonstrates the influence of structural and interpersonal factors on policy implementation, which has been overlooked in studies of frontline bureaucracies.