This article explores how multiple health risks in municipalities with Roma settlements in Slovakia are related to the varieties of local governance and the authorities’ conduct towards the local Roma population. The first part of the paper describes the situation in Roma settlements from the perspective of unequal access to sewerage and water pipelines. Introduced here are data on identified contagious diseases that correlated multiple health risks with the lack of sanitation and/or water infrastructure. The second section of the paper put forth typologies of government approaches towards the Roma, which based on ethnographic fieldwork, allows us to identify factors of attitudinal, structural and policy-oriented nature. Research results point to a “triad” of key circumstances: these are the structural conditions in municipalities and the history of local inter-ethnic relations and attitude of authorities towards Roma. Finally, possible solutions and approaches regarding how to mitigate the multiple health risks are discussed. It is suggested that on the one hand, in many villages there is a profound institutional discrimination of Roma with respect to water and sanitation infrastructure; on the other hand, water services are increasingly becoming an expensive commodity that not everyone can afford. The article concludes with discussion on enabling conditions and ways to ensure access to basic infrastructure in rural Roma communities. The solution is not only a compliance with principles of non-discrimination and existing technical norms and standards but also in securing the accessible funding for construction of the sanitation infrastructure in a smart way, including innovations and operation of cheaper and environmentally responsible sanitation technologies.