‘Five minutes earlier, you were giving hope’: Reflections from interviews with doctors conducting assessments for South Africa’s childhood disability Care Dependency Grant

Abstract

Background: In South Africa, medical doctors functionally decide whether a primary caregiver can access state-funded social assistance cash transfers (‘social grants’) for the care of their disabled child. In this paper, we unpack the subjective experiences of doctors involved in conducting assessments for the care dependency grant, designed to support the cost of disabled children’s specific needs. Methods: Individual in-depth interviews were conducted with five paediatric doctors who practice and regularly conduct assessments for the care dependency grant at three Cape Town public sector hospitals. Analysis was thematic and used deductive coding. Results: The doctors we interviewed were aware that these grants were probably shared among household members but felt this was acceptable, as it contributed to the child’s wellbeing. Doctors seemed to be applying nuanced, individualised assessments but often felt the need to simplify the documentation of these assessments, sometimes even bending the rules, to ensure access for their patients. Doctors’ primary allegiance in these processes appeared to be to their patients. They identified more with their caring responsibilities than their bureaucratic gate-keeping role but nonetheless felt a heavy responsibility for decision-making, in the context of extremely strained public resources and a lack of guidance from the government’s social assistance implementation agency. Conclusions: The hyperlocal practices and approaches that doctors described allows for perception of the messier – but also more accurate – details of the system that is actually in place. Doctors’ narratives also reflect long-standing inattention to the ‘trickle down’ of guidelines to frontline implementers of disability-related grants. This cadre is a valuable but under-utilised source of evidence and information about the real-world functioning of disability-related grants administration and they should be actively included in implementation planning.