Caring, pragmatic and discriminatory: how private paediatric outpatient providers normalise unequal care for Roma-ethnographic findings from affluent Slovakia.

backgroundHealthcare providers may enact discriminatory practices while perceiving themselves as caring and pragmatic. Whilst anti-Roma discrimination in Central and Eastern European healthcare has been documented in hospital and emergency settings in poorer regions, less is known about routine outpatient care in affluent areas. This ethnographic study examines how private paediatric outpatient providers in Slovakia’s most affluent region normalise unequal care for Roma families through everyday practices rationalised as contextually appropriate responses.

methodsThe study was conducted between 2023 and 2025 in three private paediatric outpatient clinics in Slovakia’s Bratislava Region, the country’s most economically developed area. Data were collected through extended participant observation via job shadowing and follow-up in-depth interviews with healthcare professionals. Drawing on Bourdieu’s theory of practice, intergroup contact theory, and Slovak anti-discrimination law, we analysed discriminatory staff behaviours and justifications as embedded in organisational culture, using domain-based coding in ATLAS.ti followed by thematic and comparative syntheses.

resultsWe identified nine types of discriminatory practices towards Roma caregivers, including mockery, underestimation, biased clinical decision-making, and informal gatekeeping. These practices were not understood by their perpetrators as discriminatory but rather framed as caring, pragmatic responses to seven kinds of contextual circumstances—ranging from alleged Roma-specific deficits to reputational concerns—mirroring and extending mechanisms previously identified in hospital and emergency settings in poorer regions. Compared to previous findings, more favourable living conditions for Roma and greater organisational autonomy among private providers appeared to prevent frustrated misconduct yet opened the door for ‘charitable’ forms of discriminatory paternalism. Providers framed these practices as pragmatic adaptations and exceptional care, generating moral credit that obscured unequal standards.

conclusionsDiscriminatory practices against Roma in paediatric outpatient care are routinised and structurally supported, with healthcare staff rationalising these behaviours as caring, pragmatic responses to broader societal issues. Addressing these organisational cultures of normalised, implicit racism requires systemic reforms extending beyond healthcare to challenge underlying societal anti-Roma sentiments and expectations.