Transitioning to Sustainable Administrative Gatekeeping in Access to Social Grants for South African Adult Persons with Disabilities

: This article explores the efﬁciency in the administration of social grants for adult persons with disabilities (PWDs) in the Northern Cape province of South Africa. The focus, in particular, is on explaining why, despite a gatekeeping element, adult PWDs presenting with the same medical condition, with mild or no veriﬁable impairment, keep returning and are allowed through the system, only to be rejected again, citing the same reasons as before. Administrative gatekeeping, as illustrated in the 2011 Social Grants Disability Management Model, does not extend beyond (i) verifying the correctness of supporting documents and (ii) checking documented proof of medical history to ascertain that applicants of social grants for adult PWDs are not booked for medical assessments within three months of their last assessment. This points to a weakness in the system, as the screening ofﬁcials cannot turn away applicants of social grants for adult PWDs for any other reason once the documents are veriﬁed as correct. Here, we report the ﬁndings from responses to structured telephone interviews and structured face-to-face interviews with applicants of social grants for adult PWDs who are residents of the Northern Cape province of South Africa. We conclude that socio-economic circumstances, rather than impairment, are the main drivers for adult PWDs to keep on applying for social grants for adult PWDs and we offer some strategies for addressing this predicament to contribute to a sustainable and an efﬁcient, effective, and economical administration process. The study created a platform for applicants of social grants for adult PWDs to provide insight into the administration process and practices governing social grants for adult PWDs in the Northern Cape during structured telephonic interviews and structured face-to-face interviews. Based on their responses, the following are recommended to improve the efﬁciency and sustainability in the administration of social grants for adult PWDs.


Introduction
Section 195(1)(b) of the South African Constitution (1996) [1], the White Paper on Transforming Public Service Delivery (1997) [2], and the Public Finance Management Act, 1999 (Act 1 of 1999) [3], call for an efficient (doing things the right way), effective (doing the right things) and economical (at the lowest possible cost) administration of social services. In South African Social Security Agency (SASSA) terminology, administration entails subjecting applicants to SASSA processes and procedures by collecting and collating necessary information to determine their eligibility for social grants for adult persons with disabilities (PWDs) in terms of the Social Assistance Act, 2004 (Act 13 of 2004 as amended) [4], and its regulations promulgated in 2008. In line with the progressive legislative prescripts in South Africa, several improvements were made in the rendering of sustainable social grants since the merging of the different administrations after becoming a democracy in 1994 and making social grants the responsibility of the national government. These improvements included, first, the establishment of SASSA in 2006, in terms of the South African Social Security Agency Act 2004 (Act 9 of 2004) [5], as an entity of the Department of Social Development, tasked with administration and payment of social grants. Second, the 2011 Social Grants Disability Management Model (SGDMM) was introduced to ensure standardisation and uniformity of all disability-related processes in an environment where quality services are rendered [6]. Administrative gatekeeping, one of the elements of the 2011 SGDMM, was intended for SASSA officials to screen potential applicants for social grants for adult PWDs and to ensure that only those with medical records to prove eligibility for the social grants go through for medical assessment by a contracted medical doctor.
However, in the Northern Cape province, the number of applications for social grants for adult PWDs has not decreased year on year (as per the expected norm), and neither has the number of rejections. An applicant is a person who applies for a social grant for adult PWDs in respect of himself or herself or on behalf of another person in terms of the Social Assistance Act, 2004 (Act 13 of 2004 as amended) [4], and its applicable regulations. In terms of the aforementioned act, the applicant of a social grant for adult PWDs should be a resident or citizen of the Republic of South Africa aged between 19-59 years old, with a medical condition that causes moderate to severe functional impairment. The statistics from 2012/13 indicated that 36,989 medical assessments were conducted. This number increased to 39,533 [7]. For the medical assessments conducted for adult PWDs in 2012-2018, the rejection rate remained at an average of 29% throughout the years [8]. Thus, despite the enforcement of administrative gatekeeping by the SASSA officials, as prescribed by the 2011 SGDMM [9], the high number of rejections remains constant.
The study is based in the Northern Cape, one of the nine provinces in South Africa. It is the biggest province geographically, covering an area of 372,889 km 2 , but it is sparsely populated. Despite being the most sparsely populated province, the region had the highest number of social grants for adult PWDs in payment, in proportion to the total number of social grants in payment during the financial year ending 31 March 2018 [8]. The number of social grants for adult PWDs was recorded at 12.85%, which is 5.65% higher than the national average [8].
The research presented in this article is part of a doctoral study, titled, "The Administration of Social Grants for Adult Persons with Disabilities in the Northern Cape". Among other things, the 2011 SGDMM identifies three stakeholders critical to the efficient administration of social grants for adult PWDs, namely SASSA officials, contracted medical doctors, and applicants of social grants for adult PWDs, (the focus of this article). We explore the reasons why, despite a gatekeeping element, adult PWDs presenting with the same medical condition, with mild or no verifiable impairment whatsoever, keep returning and are allowed through the system, only to be rejected again, citing the same reasons as before. In our conclusion, we advocate for policymakers to (i) develop clear, integrated policy guidelines to administer social grants for adult PWDs and (ii) consider capturing the recommendations of this study in the accompanying South African Regulations to the Social Assistance Act, 2004 (Act 13 of 2004 as amended) [4]. This could greatly reduce service delivery costs as well as time and energy spent in the administration of social grants for adult PWDs, and could contribute to a sustainable and an efficient, effective, and economical administration process.
The concept of disability refers to impairments, activity limitations and participation restrictions, as well as to the negative aspects of the interaction between an individual (with a health condition) and that individual's contextual (environmental and personal) factors [10] (p. 4), [11] (p. 8). The 2010 South African Social Assistance Amendment Bill defines disability in respect of an applicant for a social grant for adult PWDs as a moderate or severe limitation to a person's ability to function as a result of a physical, sensory, communication, intellectual or mental disability, thus rendering a person unable to obtain the means needed to enable a person to provide for his or her own maintenance, or be gainfully employed [4].
Disability, according to this definition, is not only limited to the physical but encompasses other forms of disability as well. Thus, PWDs are persons with a physical, intellectual, or sensory impairment that permanently limits their daily functioning. For this study, an adult PWD refers to a person aged between 19-59 years and eligible for social grants for adult PWDs [12]. Social security in general, and the social grant for adult PWDs in particular, is aimed at poverty alleviation, income replacement, compensation, aid for "extra needs" and prevention of social exclusion, as PWDs are often faced with both a lack of earnings and costs related to a specific disability [13] (p. 470), [14]. While in some countries adult PWDs receive disability grants (DGs) purely based on their disability or invalidity, in South Africa, they are based on both the level of impairment and need. In South Africa, social assistance operates on the assumption that recipients of social grants do not have access to employment due to their level of impairment, rather than attributing their inability to a lack of opportunities.

Literature Review
It is estimated that about 15% of the world's population has some kind of disability [10]. Internationally, social assistance provided for adult PWDs is receiving increased attention. This is because the global recession around 2010 led to massive job losses and swelling unemployment figures worldwide, exacerbating the plight of the poor. To curb this dire situation, in June 2012 the International Labour Organisation adopted Recommendation No. 202, which provides a framework for member states to extend the coverage of social security, which includes, among other things, basic income security for persons of active age who are unable to earn sufficient income in case of sickness, unemployment, maternity or disability [15] (p. 37), [16] (p. 26). Before that, in December 2006, the Convention on the Rights of Persons with Disabilities (CRPD) was adopted by the United Nations (UN) General Assembly to promote, protect and ensure equality and non-discrimination in the realisation of the rights of PWDs [17] (p. 5).
As a "State Party" to the UN CRPD, South Africa, like all member states, is bound by its provisions that refer to the general obligations undertaken by states to ensure and promote the full realisation of the human rights and fundamental freedoms of all PWDs without discrimination of any kind based on disability [18]. This obligation is fully acknowledged by the South African government and has culminated in legislation to address the human rights needs of adult PWDs.
A literature review revealed that interest in the present subject matter has mainly been related to disability in the workplace, with an emphasis on mainstreaming, discrimination, or how to accommodate adult PWDs in the workplace, as well as the impact of social grants for adult PWDs on recipients. The following are the main findings from the international literature by Maestas et al. [19], Loyalka et al. [20] and Wind et al. [21], as well as those studies on the CRPD by Murungi [18], Ladner [22], Walker [23], Vlaicu et al. [24] and Xu and Chen [25].
The study on the evolution of models of disability related to the topic under investigation is from Zajadacz [26] (p. 190), who perceives disability as a multifaceted phenomenon, reflecting an interface between physical features and the elements of the environment in which the disabled lives. Retief and Letšosa [11] acknowledge the three universal categories of models of disability: the "medical" models, where disability is seen as a disease of an individual; the "social" models, where disability is a product of the environment; and the models in which disability is the result of the individual-environment interaction. This article has outlined a further six models of disability that continue to impact how people conceive PWDs but stated that these are by no means the only models of disability that are relevant in the 21st century. In support, Zajadacz [26] noted a visible tendency towards the need for a flexible "mix of various models" in the development of accessible tourism for PWDs.
One international study related to the topic under investigation is from Maestas et al. [19], who examined whether the Social Security Disability Benefits (SSDI) disincentive effect varies across individuals, and if so, to what extent, and in what ways. Maestas et al. [19] found that the SSDI caseload has become increasingly dominated by individuals with impairments and concluded that employment of the marginal programme entrant would be on average 28 percentage points greater in the absence of SSDI receipt, even though the disincentive effect is not constant across individuals.
Another international study, by Loyalka et al. [20], reports on the degree to which household income is negatively associated with the prevalence of different types of disability despite the rapid reforms in social security. They concluded that although both the amount and coverage of social security for households with disabilities are increasing, this is still not enough to offset the income differential between households with and without disabled persons.
Furthermore, Wind et al. [21] assessed the expectations of Dutch claimants applying for a disability benefit, the rationale behind these expectations and their value in the process of evaluating the disability. They found that low education levels, higher age and low workability scores were correlated with the expectation of receiving a benefit, and they concluded that patients can predict the outcome of their application for a disability benefit.
Finally, three international studies on the CRPD, conducted by Murungi [18], Ladner [22] and Walker [23], respectively, focused on Article 24 of the UN CRPD and its applicability to (i) children's socio-economic and disability rights, (ii) application of computer science for PWDs in the workplace (iii) and people with intellectual disabilities, respectively.
Eleven South African studies related to the topic under investigation (i) explore the inclusion of HIV/AIDS as a criterion for awarding social grants for adult PWDs, and the unintended consequences and perverse incentives thereof [27][28][29][30][31]; (ii) the administrative processes of social grants for adult PWDs [32][33][34][35]; (iii) analyses of the characteristics of people who receive a disability grant, the role of a disability grant in the lives of recipients, poverty and disability-related costs [36,37]. During the literature review, it was discovered that although these studies have been conducted relating to both social grants in general and social grants for adult PWDs in particular, only two relate to the administration of social grants for adult PWDs. The only two studies that focused on the administrative processes in relation to social grants for adult PWDs [32,34] are somewhat outdated, as they were conducted long before the introduction of the 2011 SGDMM. Even in the studies found, the role of disability grants in mitigating the socio-economic impact of disability, the possible positive impact, or the perverse incentives of receiving the social grants for adult PWDs seems to be the driving forces behind conducting studies about disability and social grants for adult PWDs.

Study Design and Procedure
Structured telephone interviews and structured face-to-face interviews (comprising 15 questions) were conducted with applicants of social grants for adult PWDs, all of whom are residents of the Northern Cape province of South Africa. The researchers followed the phenomenological research approach, which falls within the interpretivist paradigm. Before the collection of the primary data commenced, a pilot study was conducted, during which the validity of the research instrument was tested to investigate the feasibility of the planned research project and to elucidate possible deficiencies in the measurement procedure [38] (p. 179). The respondents who participated in the pilot did not form part of the final group of respondents [39].

Population, Sample Size and Sampling Technique
Applicants of social grants for adult PWDs were categorised into successful (n = 61,514) and unsuccessful applicants (n = 4686) (Table 1). Successful applicants were those who received permanent social grants for adult PWDs during the 2017/18 financial year, while unsuccessful applicants were those who received temporary disability grants for adult PWDs during the 2017/18 financial year and had applied for internal reconsideration at least once during the period 2011-2018 (Table 1). Total n = 149 (54%) n = 29 unsuccessful applicants (telephone interviews) n = 120 unsuccessful applicants (face-to-face interviews)
Snowball sampling was used to select applicants of social grants for adult PWDs to participate in structured telephonic interviews and structured face-to-face interviews [40] (p. 55). SASSA Northern Cape had, at the time, scheduled several outreach programmes to migrate the beneficiaries of social grants from the then payment service provider, Cash Paymaster Services, to the South African Post Office [8]. Ten such outreach programmes were scheduled across the five districts of the Northern Cape region from October to December 2018. The researcher used the opportunity created by the SASSA outreach programmes to issue new payment cards as a platform to approach applicants of social grants for adult PWDs to participate in the study. Those willing to participate were interviewed on the spot after signing the consent forms.

Reliability and Ethical Aspects
The reliability of a measure refers to its capacity to consistently reflect the phenomenon being measured [39]. However, ensuring reliability is difficult because human nature is not static, which means that using the same instrument on the same subjects is unlikely to produce similar results. This was mitigated by giving respondents the option to give additional information or responses to those already provided by the researcher.
Ethical considerations when conducting research involve the confidentiality of results and findings of the study and the protection of the identities of the respondents [39]. The respondents in the study were first issued with a letter explaining the purpose of the research, the expected duration and the procedures (informed consent) and were then allowed to indicate, in writing, their willingness or unwillingness to participate in the study (freedom of choice). The respondents were very clearly told that they could withdraw at any point during the study should they feel uncomfortable.

Statistical Method and Data Analysis
Using the Statistical Package for the Social Sciences (SPSS) 20 statistical analysis software, the data were organised, tabulated and analysed using constructive one-way and two-way frequency distribution tables for all questions and response patterns of different sub-groups through cross-tabulations. Descriptive statistics were used to summarise the results in terms of frequencies and percentages for categorical variables, means, or medians, as well as maxima and minima for numerical variables [41].

Research Results
Two hundred and seventy-six (276) applicants responded. A total of 22 successful applicants and 29 unsuccessful applicants (n = 51) participated in structured telephonic interviews, whereas 105 successful and 120 unsuccessful applicants (n = 225) participated in structured face-to-face interviews. Thus, in total, 127 (46%) successful and 149 (54%) unsuccessful applicants participated (n = 276). (Table 1). Of the 276 structured interviews with successful and unsuccessful applicants of social grants for adult PWDs, 51 (18.5%) were conducted over the telephone, while 225 (81.5%) were conducted face to face.
The responses were organised according to the three sections in the structured interview schedule, namely, knowledge of acts and policies on social grants for adult PWDs, the process of social grants for adult PWDs, and attitude towards social grants for adult PWDs. As respondents could select more than one response category, the number of responses is often more than the number of respondents.

Knowledge of Acts and Policies on Social Grants for Adult PWDs
Five questions in section A of the structured interview schedule aimed to examine adult PWDs' knowledge of the available legislation governing the administration of social grants for adult PWDs. The responses to the five questions are discussed in this section.
Respondents were asked why they applied for a social grant for adult PWDs. Four hundred and twenty-six (n = 426) responses were captured. The response category that received the highest number of responses was illness (n = 161 or 37.8%), followed by a permanent physical disability (n = 107 or 25.1%) and temporary physical disability (n = 93 or 21.8%). The other response categories (temporary mental condition, no source of income and permanent mental disability) all received less than 7%. Thus, it appears that rather than disability in its "traditional" form, impairment due to illness, which is mostly temporary, is the main reason adult PWDs approach SASSA to apply for and be awarded social grants for adult PWDs. From the 161 responses to the variable of illness, the three highest response categories were hypertension (n = 26 or 16%), Tuberculosis (TB) (n = 25 or 15.5%) and HIV (n = 22 or 13.7%), which are mainly-with the right intervention-manageable chronic illnesses.
In addition, other variables received smaller percentages of responses, as shown in Figure 1. The following seventeen response categories all received less than 9%: "other" 8.7%; epilepsy 8.1%; diabetes 7.5%; heart disease and backache 3.7% each; arthritis, asthma and mental illness 3.1% each; sore eyes 2.5%; stroke, recurring headaches and old age 1.9% each; chronic illness, nosebleeds, bipolar, lung disease and a broken arm 1.2% each (Figure 1). The illnesses specified under the response category "other" were pneumonia, painful joints, bronchitis, swollen neck, stab wound on left arm, swollen legs, grant-inaid for caring for a daughter with disabilities, amputated finger, accident, broken knee, numb feet, broken leg, left hand not working and knee pain (not indicated in Figure 1). From Figure 1 it is noted that manageable chronic illnesses like hypertension, diabetes, HIV/AIDS and TB are the main reasons adult PWDs apply for social grants for adult PWDs. In an additional question, a significant number of respondents (n = 166 or 60%) indicated that social grants for adult PWDs were a source of income for those unable to support themselves due to impairment. Respondents were asked how long they were treated for a medical or mental condition before they were referred to SASSA. A total of 276 responses were recorded. Of these, 122 (44.2%) respondents indicated that they received treatments for more than a year before they were referred to SASSA to apply for social grants for adult PWDs. Sixty-one (22.1%) respondents indicated a period from 1-3 months, whilst the rest indicated anything from four to twelve months. Even though it takes six months or more on treatment before adult PWDs are referred to SASSA, the longest period any of the respondents had been on treatment before they were referred is more than 20 years, though they were in the minority (n = 3 or 6.7%).
It was also important to know who initiated the referral to SASSA for the application of social grants for adult PWDs. A total of 294 responses were recorded. The majority of the respondents (n = 202 or 68.7%) indicated that a healthcare practitioner initiated the referral. Smaller percentages were identified as self-referrals (n = 45 or 15.3%), whilst less than 8% mentioned family, friends, community leaders, advertisements on television and outreach programmes. It thus appears that, despite the clear criteria of the screening process, many respondents still walk into SASSA offices without appropriate referrals to apply for and be awarded social grants for adult PWDs.
The response rate to the question of why government-provided social grants for adult PWDs was 276. The response category that received the highest score accurately indicated that social grants for adult PWDs were a source of income for those unable to support themselves due to impairment (n = 166 or 60%). The next two response categories with the highest scores indicated that government provides social grants for adult PWDs as a source of income for the unemployed (n = 77 or 27.9%), while 19 (6.9%) indicated that they are a source of income for adults aged 19-59 years of age. Less than 1% of responses (0.4%) considered social grants for adult PWDs as a source of income for previous taxpayers, while 13 respondents (4.7%) indicated the response category "other" as a reason for the provision of social grants for adult PWDs by the government.
In a final question in this category, respondents were asked what, in their opinion, the qualifying criteria for social grants for adult PWDs should be. The response rate was 356. The response category that received the highest score was the one that opted for not changing the qualifying criteria for social grants for adult PWDs (n = 128 or 36%). The second-highest score category, with 118 responses (33.2%), was the one that indicated that social grants should be made available to all disabled people, regardless of the severity of impairment, while the third-highest score (n = 74 or 20.8%) was the category that would like all unemployed people to receive social grants for adult PWDs. The last two response categories-make it available only to previous taxpayers aged less than 60 years (n = 8 or 2.2%) and the response category "other" (n = 28 or 7.9%)-each made up less than 10% of the remaining responses. It is interesting to note that the number of responses in favour of leaving the criteria as they are (n = 128 or 36%) was almost the same as the number of successful applicants who participated in the study (n = 127). It appears from the responses that those who were eventually permanently awarded social grants for adult PWDs considered the current qualifying criteria to be fair.

Process of Administration of Social Grants for Adult PWDs
The five questions posed in section B of the structured interview schedule were aimed at examining the actual experiences and challenges of adult PWDs during the administration process of social grants for adult PWDs, in relation to the 2011 SGDMM. The responses are presented in this section.
Respondents were asked, once they were referred, how long it took for them to get to a SASSA office to present a referral letter. A total of 276 responses were recorded. The response category that received the highest score indicates that it took less than a week to get to a SASSA office to present a referral letter once it is issued (n = 135 or 48.9%). The second-highest score category, with 105 responses (38%), indicates that it took longer than a week, whereas according to the third-highest score category it took less than a day to get to a SASSA office to present a referral letter (n = 36 or 13%). It was noted that, even though such cases were in the minority, it is feasible to present a referral letter to SASSA within a day once it is issued to kickstart the process of application. However, in extreme but rare cases, it can take up to three months for an adult PWD to present a referral letter to SASSA once it is issued.
The next question was about how many times an applicant visited a SASSA office before the process (screening to approval) was completed. A total of 276 responses were recorded. The response category that received the highest score indicated that it took three to five visits to a SASSA office before the process (screening to approval) was completed (n = 161 or 58.3%). The second-highest score category, with 58 responses (21%), indicated that it took six to ten visits, whereas according to 52 respondents (18.8%), it only took two visits. There were only five responses (1.8%) indicating that it took more than ten visits. It appeared that despite SASSA advocating for a one-day turnaround time, it still takes three to five visits to a SASSA office before the process from screening to approval can be concluded.
The process of administration of social grants for adult PWDs is also influenced by a delay between referral and actual application for the grants. Respondents were asked what the possible reason(s) could be and were provided with pre-coded options to choose from. Three hundred and sixty-six (n = 366) responses were captured. The response category that received the highest number of responses was the unavailability of doctors (n = 102 or 27.9%), misinformation (n = 86 or 23.5%), transport (n = 68 or 18.6%) and overbooked doctors (n = 47 or 12.8%). In the response category "other", non-adherence to office hours and system shutdowns were mentioned as reasons for delays. From these responses, it was acknowledged that even though the unavailability of contracted medical doctors is a real concern, SASSA officials and SASSA systems, and how they are managed, contribute to further delays.
The last two questions in this section focused on the screening-to-approval process. From the 276 responses, it appears that it is not the administration process in itself that is problematic, but rather the management of the SASSA offices, evident from practices such as poor adherence to working hours and outdated business processes. Respondents further indicated that (i) the process is too long, (ii) they are turned away without explanation, (iii) the queues are too long, (iv) inaccurate information is provided by SASSA officials, (v) SASSA officials go to lunch, leaving people waiting, (vi) SASSA offices close at 14:00, (vii) the SocPen system is constantly offline, (viii) people are awarded temporary disability grants despite being permanently disabled/sick and (ix) returning applicants are expected to follow the same process as new applicants. The respondents were then allowed to make suggestions about making the screening-to-approval process more efficient. i.
Four hundred and forty-six (n = 446) responses were captured. It was surprising to note that a significant number of respondents (n = 124 or 27.8%) indicated that they were satisfied with the screening-to-approval process as it is. However, the response category that received the highest number of responses (n = 125 or 28%) was that some steps, like referral and booking, should be eliminated from the process. Other responses included: ii. Activating mobile services for the processing of social grants for adult PWDs. iii. Integrating the SASSA system with those of health facilities to automatically award grants to those who have had medical intervention. iv. SASSA officials should conduct home visits for those applicants who are bedridden. v.
SASSA's working/operating hours should be extended, possibly to accommodate working applicants or those who rely on others, who might be employed, for assistance. vi. Procuring more office space with appropriate equipment and waiting facilities to make waiting in long queues bearable. vii. Employing public servants who are committed to working well with applicants. viii. Putting better queue management strategies in place. xi. Employing an IT specialist to tackle system challenges (SocPen) hands-on instead of instructing applicants to go home and return the next day.
From the responses in this section, one can deduce that there is an urgent need for SASSA to review its screening-to-approval processes and overhaul its systems to keep up with the changing needs of its customers and make the process sustainable.

Attitude towards Social Grants for Adult PWDs
Five questions were posed in this section and the responses are indicated below. Respondents were asked how many times they had applied for a social grant for adult PWDs before their application was successful. A total of 276 responses were recorded. The response category that received the highest score indicated that it took three to five applications for a social grant for adult PWDs before the application was successful (n = 109 or 39.5%), while the two second-highest scores, 60 responses (21.7%) each, indicated once or twice, respectively. The fourth-highest score, 47 responses (17%), indicated that respondents had applied more than five times before the application was successful.
Respondents were also asked if they were eventually successful, what condition it was for. A total of 216 responses were recorded. The response category that received the highest score, with 127 responses (58.8%), indicated that the applications were successful for the same medical or mental condition respondents previously applied for. The second-highest score, with 69 responses (31.9%), showed that the application was successful due to a new medical condition. Only 19 responses (8.8%) attributed subsequent success to the same medical or mental condition, but a different contracted medical doctor. Only one response (0.4%) specified a reason other than those provided as options, which was the fact that the respondent is now on treatment and taking medication for the condition. It thus appears as if, despite applying on average three to five times before the grants were approved, the applications were most successful for the same medical or mental condition respondents previously applied for.
Applicants were asked how many times they think a person can apply for a social grant. A total of 276 responses were recorded. The response category that received the highest score indicated that a person can apply more than once, as long as the medical or mental condition persists (n = 135 or 48.9%), while the second-highest score, with 71 responses (25.7%), indicated more than once, as long as the person with a medical or mental condition is unemployed. The third score, with 38 responses (13.8%), specified "other". According to 38 respondents (13.8%), a person can apply for a social grant for adult PWDs more than once, given one of the following: (i) the medical or mental condition persists, and the person is unemployed; (ii) a person does not have a source of income; (iii) a medical doctor refers a person to apply for social grants for adult PWDs; (iv) until the contracted medical doctor awards the social grant for adult PWDs permanently; (v) if it is a temporary grant, as soon as the social grant for adult PWDs lapses; (vi) as long as a person is sick; (vii) every three months after a rejection; and (viii) every six months after a rejection (n = 2 or 5.3%). Twenty-nine respondents (10.5%) indicated more than once as long as it is a different medical doctor. It appears that the extent of the medical or mental condition determines the number of times a person can keep on applying for social grants for adult PWDs. However, 10.5% thought that dealing with different doctors is the determining factor in how many applications one can make.
To the question, "What do you think makes people keep on applying for social grants for adult PWDs despite being rejected several times?" the response rate was 506. The response category that received the highest score was the one indicating that people keep on applying for social grants for adult PWDs because they are unemployed (n = 132 or 26.1%), while the category with the second-highest score, 120 responses (23.7%), was the one indicating that it is because the three-month period after their last medical assessment has lapsed. A further 99 (19.6%) respondents indicated that people keep on applying for social grants for adult PWDs due to the same medical or mental condition, but they are convinced they qualify, while 50 respondents (11.7%) indicated that it is because a new medical or mental condition emerged. The other two response categories (social grants are for everyone, 4.4%, and a person is employed but earning too little, 1.2%) both received less than 5%.
In the response category "other" (n = 68 or 13.4%), the following reasons were given as contributing to repeat applications for social grants for adult PWDs despite being rejected several times: (i) poverty; (ii) when awarding temporary social grants for a permanent medical or mental condition, adult PWDs will keep on applying every six, nine and twelve months; (iii) no source of income; (iv) adult PWDs who are on chronic medication need money to buy food; (v) adult PWDs do not consistently attend the health clinic and do not take medication as prescribed; and (vi) adult PWDs cannot work anymore (n = 4 or 5.9%). It is unfortunate, but it appears that social grants for adult PWDs are seen as a buffer against the effects of unemployment and the absence of income.
The final question in this section asked the respondents to suggest recommendations for improving efficiency in the administration of social grants for adult PWDs in the Northern Cape region. A total of 349 responses to this question were captured. The response category that received the highest score, 125 responses (35.8%), recommended reviewing the current policies governing the administration of social grants for adult PWDs, while the second-highest scoring category, with 118 responses (33.8%), recommended that the process should be left as is. The third-highest scoring category, with 53 responses (15.2%), recommended that the current policies should be maintained, but that gatekeeping should be diligently enforced. The fourth-highest scoring category, with 33 responses (9.5%), recommended that the SASSA system should be integrated with that of health facilities. Finally, 20 respondents (5.7%) made other recommendations in addition to those specified in the structured interview schedule. The 20 responses in the category "other" recommended that efficiency in the administration of social grants for adult PWDs could be improved by providing permanent social grants for adult PWDs to persons who are permanently disabled or sick. That is, once approved, social grants should not lapse but be permanent. The following additional recommendations were made: i.
Socio-economic circumstances should be taken into consideration when recommending social grants for adult PWDs. ii. Adult PWDs should be educated on their rights and responsibilities regarding social grants for adult PWDs. iii. The government should go to the people to see how they live. Then the government can make an informed decision about the qualifying criteria for social grants for adult PWDs.
It appears that a multi-faceted approach is required if efficient, effective, and economical administration of social grants for adult PWDs are to be improved. A multi-faceted approach implies considering various innovative systems (e.g., electronic queue management, amended qualifying criteria, stakeholder education, flexible working hours and adding more resources).

Discussion
Concerning the respondents' knowledge of acts and policies on social grants for adult PWDs, applicants showed that they do know the acts and policies governing the administration of the grants, although their knowledge is not always accurate or detailed. However, despite this status, several applicants still approached SASSA to apply for social grants for adult PWDs citing unemployment and/or a lack of income, rather than, as would be expected, impairment. Illness, especially manageable chronic illnesses such as hypertension, diabetes and HIV/AIDS, is the main reason adult PWDs approach SASSA to apply for social grants for adult PWDs. In addition, repeat applications for social grants for adult PWDs for the same medical or mental condition over several years are common. Thus, it can be deduced that in-depth knowledge of acts and policies on the administration of social grants for adult PWDs appears to be lacking.
For the section of questions concerning the process of administration of social grants for adult PWDs, it was noted that while the medical or mental condition should ideally determine the time before an applicant on treatment is referred to SASSA, in the absence of a uniform standardised timeframe, the treating medical doctor unilaterally decides how long it takes before he or she refers an adult PWD to SASSA to apply for a social grant. The unavailability of contracted medical doctors was notably also cited as the main cause of delays between referral and actual application. Further delays were caused by perceived management weaknesses within SASSA in executing the process efficiently. The current process on the administration of social grants for adult PWDs is not designed in such a way that it could be concluded in one trip. It takes, on average, three to five trips to a SASSA office or service point before the process of screening to approval can be completed. Thus, the reason for application does not influence the (i) number of trips to the SASSA office, (ii) the number of applications before one is successful, or (iii) turnaround time. It takes an average of three months, depending on the availability of all the necessary resources, for an applicant to go through the complete administration process of social grants for adult PWDs.
Two conclusions were drawn from the findings on the respondents' attitude towards social grants for adult PWDs. First, it was noted that there is an entrenched misconstrued belief that persistence in applying for these grants, despite presenting with the same medical or mental condition, increases one's chances of being awarded a grant. This belief is probably reinforced by SASSA, as it is quite common for applicants who were previously rejected to be awarded a grant. The reasons for this could be that (i) the applicant has a deteriorating medical or mental condition, (ii) SASSA officials or contracted medical doctors are trying to correct a previous error, or (ii) SASSA officials or contracted medical doctors allow sympathy (personal bias) to influence their decisions.
The second conclusion drawn in this section is that social grants for adult PWDs are considered a source of income for all those who are aged 19-59 years and are without work or the means to support themselves or their dependents. The current socio-economic circumstances of the applicants, the absence of alternative safety nets for those aged between 19-59 years and inadequate beneficiary education are the reasons adult PWDs keep on applying for social grants for adult PWDs despite being rejected time and time again. Disability, inability to compete in the open labour market, impairment, inability to perform certain functions and a lack of income should all form part of the qualifying criteria to apply for and be awarded social grants for adult PWDs.

Recommendations towards Transitioning to Sustainable Administrative Gatekeeping in the Administration of Social Grants for Adult PWDs
The study created a platform for applicants of social grants for adult PWDs to provide insight into the administration process and practices governing social grants for adult PWDs in the Northern Cape during structured telephonic interviews and structured faceto-face interviews. Based on their responses, the following are recommended to improve the efficiency and sustainability in the administration of social grants for adult PWDs.
Employment opportunities for adult PWDs in South Africa remain extremely limited, stereotyped and inaccessible [42,43]. According to Statistics SA, the country's official unemployment rate during the fourth quarter of 2020 rose by 1.7 percentage points from the previous quarter to 32.5% in February 2021 [43]. Due to limited educational qualifications, skills, and expertise in finding and keeping jobs that pay well enough to enable them to be self-supporting, many adult PWDs apply for social grants for adult PWDs not because they are impaired to the extent that they cannot support themselves, but because they lack the necessary skills and expertise to secure a job in the long term. It is against this serious predicament, alongside the impact of COVID-19 on the South African economy, that the focus needs to be on facilitating training for PWDs in employment opportunities.
There is a need to come up with interventions for those who see social grants for adult PWDs as a source of income for the unemployed in general, rather than for those who are unemployed due to impairment [37]. The reality is that some of those aged between 19-59 years might never experience the joy of having a job, either out of a lack of interest, due to a lack of the necessary qualifications, skills and expertise, or due to the socio-economic status of the country, among other things [43]. The government needs to put programmes and interventions in place to divert these people from the social grants system and prevent them from clogging it unnecessarily. A typical solution could be to link applicants (successful and unsuccessful) of social grants for adult PWDs to other development programmes.
In addition to government intervention, there is a further need for professional intervention for those repeat applicants of social grants for adult PWDs who are found to be mildly impaired. Rather than turning them away without being offered alternative forms of assistance, SASSA officials should refer these applicants to other professionals for intervention that will prevent them from treating social grants for adult PWDs like random awards to whoever happens to be in the right place at the right time. In this regard, other professionals who are better placed to deal with health and social issues, should get involved and assist with intervention programmes for adult PWDs.
The community needs to become more engaged and be educated about what a social grant for adult PWDs is and what it is not [36,43]. Armed with relevant, current information, applicants would be able to approach SASSA to apply for social grants, knowing that they do meet the criteria and are not simply trying their luck. Any legislative changes should be communicated timeously and consistently. This initiative can be developed through a comprehensive communication strategy for legislation on social grants for adult PWDs.
In conclusion, we advocate for policymakers to (i) develop clear, integrated policy guidelines to administer social grants for adult PWDs and (ii) consider capturing the recommendations of this study in the accompanying South African Regulations to the Social Assistance Act, 2004 (Act 13 of 2004 as amended) [4].
The survey was carried out mainly within the Northern Cape Community of South Africa. To gain a global view of improving the efficiency in the administration of social grants for adult persons with disabilities, research should be performed in countries representing all continents. Additionally, private sector institutions, as well as parastatals, should participate in the decision-making processes. The presented survey results should not be treated as an exhaustive study but rather as a stimulus to deepen the discussion concerning issuing disability grants based on both the level of impairment and need.