A Human Rights-Based Approach to Poverty Reduction: The Role of the Right of Access to Medicine as an Element of the Right of Access to Health Care

The prevention and treatment of infectious diseases remain among the greatest challenges faced by today's developing countries. The World Health Organisation estimates that about one-third of the world's population lacks access to essential medicine, a fact which, according to the United Nations, directly contradicts the fundamental principle of health as a human right. According to the World Summit for Social Development, poor health and illness are factors that contribute to poverty, while the adverse effects of illness ensure that the poor become poorer. A lack of access to health care, amongst other rights, (including access to medicines as an element thereof) aggravates poverty. The most important provision in international law relating to the right to health is article 12 of the United Nations International Covenant on Economic, Social and Cultural Rights. Article 12(1) of this Covenant provides a broad formulation of the right to health in international law, while article 12(2) prescribes a non-exhaustive list of steps to be taken in pursuit of the highest attainable standard of health. Article 12(2), in particular, illustrates the role that adequate access to medication plays in the right of access to health care. The United Nations Committee on Economic, Social and Cultural Rights has explicitly included the provision of essential drugs as a component of the right to health care, thereby emphasising the causal link between the lack of access to essential medicines and the non-fulfilment of the right of access to health care. As with all socio-economic rights, the resource implications of the realisation of the right to health has the result that states cannot be expected to immediately comply with its obligations in respect thereof. Instead, article 2(1) of the International Covenant on Economic, Social and Cultural Rights and the General Comments of the Committee on Economic, Social and Cultural Rights place obligations on states to take deliberate, concrete and targeted steps towards expeditious and effective full realisation of the right to health, including access to medication. The measures taken to do so must, according to General Comment 3, embrace the concept of the minimum core obligation (the minimum core in relation to medicines being access to essential medicines, at the very least). In this article it is argued that adequate access to essential medicines, as an element of the right of access to health care, could contribute to the reduction of poverty. This is done by firstly discussing the human rights-based approach to poverty reduction, whereafter attention is turned to access to medicines as an element of the right to health, with specific focus on obligations in terms of the International Covenant on Economic, Social and Cultural Rights. Finally, the role of access to medicines in reducing poverty is considered. The article concludes that poverty constitutes an infringement on human rights and will not be eradicated without the fulfilment of human rights, including the right to health. The adequate fulfilment of peoples' rights of adequate access to essential medicines will enable them to achieve a higher level of well-being, thereby reducing the level of poverty which they experience. Both the right of access to health care and to essential medicines – a crucial component thereof – thus have a significant role to play in a state's poverty reduction strategies.

Poverty is so deeply rooted in most communities that it is unrealistic to assume that it can be utterly eradicated. 24 As is the case with the realisation of human rights, poverty reduction cannot be achieved immediately, 25 but is a progressive process that needs to go hand in hand with the setting of intermediary and final goals. 26 In order to understand the link between access to health care, including essential medicines, and poverty reduction, it is thus imperative to take cognisance of the progressive nature of both the realisation of human rights and poverty reduction.
Both must be measurable in order to determine whether or not adequate access to medicines indeed has an impact on poverty reduction.

A human rights-based approach to poverty
Defining poverty is no easy task. 27 The common denominator in most definitions is economic deprivation or a lack of income. 28 However, these economic definitions of poverty neglect to take into account the variety of social, cultural and political aspects thereof. 29 A successful definition must consider both aspects. 30 Such a definition must focus on the non-fulfilment of human rights without uncoupling it from a lack of economic resources. 31 Poverty is thus multidimensional in nature and for the purposes of this article cannot be defined as the mere lack of sufficient income. Consequently, a multidimensional approach to poverty will be followed.
According to this approach, the non-fulfilment of human rights is inseparably part of a lack of command over economic resources, but is not exclusively limited thereto. 32 24 UNHCHR 2002 http://www.bit.ly/13KMkyd guideline 4 para 62 (henceforth UNHCHR Human Rights Approach to Poverty Reduction Strategies). 25 UNHCHR Human Rights Approach to Poverty Reduction Strategies guideline 4 para 62. 26 UNHCHR Human Rights Approach to Poverty Reduction Strategies guideline 4 para 68. 27 In this regard see Spicker "Rights of the Poor" 3-6. See also UNCESCR 2001 http://bit.ly/14XesI1 (Poverty and the ICESCR) para 8 where it is stated that no universal definition for poverty exists. See also Matunhu 2008  According to the UN, the aforementioned multidimensional character of poverty is satisfactorily contained in Sen's capability approach. 33 This approach defines poverty as the absence or inadequate fulfilment of the basic freedom to avoid illness, for instance. 34 The extent to which a person is free to pursue good health or is free to avoid ill-health indicates the person's level of well-being. 35 The poor, however, have limited opportunities to pursue well-being, making this the defining characteristic of poverty. 36 Capabilities in this regard, refer to a person's ability in the form of freedoms and opportunities to achieve such well-being, 37 making poverty a person's lack of ability to achieve well-being through the pursuit of good health or the avoidance of illness. 38 According to the capability approach, poverty is indicative of extreme deprivation. Therefore, only a lack of those capabilities that can be classified as basic will amount to poverty. 39 However, communities have different priorities, resulting in different communities classifying different capabilities as basic. 40 The UN points out that it is possible to identify certain basic capabilities common to all communities. Amongst these are health and avoiding preventable morbidity, both of which can be assisted by the provision of access to essential medicines. 41 33 UNHCHR Human Rights and Poverty Reduction: A Conceptual Framework 6. 34 In this regard, freedom is interpreted broadly and as such includes both positive and negative freedoms. UNHCHR Human Rights and Poverty Reduction: A Conceptual Framework 9. It is this aspect of the capability approach that makes it a suitable conceptual basis for human rights. Human rights need to be respected, protected and fulfilled, all of which implies respect for freedoms. Human rights obligations and the capabilities approach thus focus on the same freedoms. In this regard see Osmani 2005  Furthermore, according to the capability approach, a lack of command over economic resources plays an important role in defining poverty as it is helpful in distinguishing between poverty and a general low level of well-being. 42 Although poverty has an economic connotation, insufficient income is not the relevant concept. The broader concept of a lack of command over economic resources, however, is. 43 Insufficient income is only one possible cause of a lack of command over economic resources. 44 Other causes include a lack of command over public goods and services, 45 inadequate access to communally owned and managed resources and inadequate control over resources made available through formal and informal networks of mutual support. 46 Poverty will result if inadequate command over any of these resources plays a role in the deterioration of basic capabilities. 47 Where the capabilities approach defines poverty as the absence or inadequate fulfilment of basic freedoms or basic capabilities enabling people to pursue wellbeing, the human rights-based approach to poverty argues that people have an inalienable right to these basic capabilities. 48 In the human rights-based approach, poverty is thus defined as the inadequate fulfilment of a person's human right to basic capabilities. 49 This approach interprets poverty broadly as the absence of the basic capabilities needed to live a dignified life. 50 Thus, poverty is not only a lack of income or economic and material resources; it is an infringement on human dignity and also on human rights. 51  Because poverty is the inadequate fulfilment of a person's human right to basic capabilities, this can be seen as the defining characteristic of poverty. 57 It has already been said above that health has been identified as a basic capability common to all communities. 58 Therefore, the conclusion can be drawn that if a person experiences inadequate or non-fulfilment of the right of access to health (and essential medicines as a component of this right), such a person will be classified as poor and experiencing a low level of well-being, in as far as these inadequacies have led to a lack of command over the necessary economic resources. 59 52 UNHCHR Date Unknown http://www.bit.ly/13lG5t9. 53 The CESCR regards this definition as a multidimensional notion of poverty which reflects the indivisibility and interdependence of all human rights. See UNCESCR Poverty and the ICESCR para 8. 54 The United Nations Universal Declaration of Human Rights (1948)  It can be noted that the health of not all who receive health care and essential medicines will reach a level enabling them to pursue a higher level of well-being, thus reducing the level of poverty experienced. In this regard it is important to distinguish between people who are ill due to the non-fulfilment or inadequate fulfilment of their right of access to health care and essential

Poverty and human rights
...Poverty reduction and human rights are not two projects, but two mutually reinforcing approaches to the same project. 60 Vulnerability sets in when there is an absence of one or more of the capabilities needed for the fulfilment of basic obligations and the enjoyment of fundamental rights. 61 The lack of security that results from these circumstances will, with time, lead to chronic poverty, which will have a seriously detrimental effect on the ability to pursue these rights in the foreseeable future. 62 One of the central ideas behind the human rights-based approach to poverty reduction is that: ...poverty reduction no longer derives merely from the fact that the poor have needs but also from the fact that they have rights -entitlements that give rise to legal obligations on the part of others. Poverty reduction then becomes more than charity, more than a moral obligation -it becomes a legal obligation. 63 As the social phenomenon that probably has the largest detrimental effect on human rights, poverty will not be eradicated without the fulfilment of human rights. 64 There exists a further dual theoretical justification behind the link between human rights and poverty. 65 Poverty in itself is seen as a denial of human rights, while the inadequate or non-fulfilment of human rights causes poverty. 66 According to the medicines, and those who are ill due to an incurable disease. Although both categories experience a low level of well-being, only the first category will be classified as poor, if a lack of command over economic resources played a role in the causal chain of events leading up to the low level of well-being. The second category of people will remain ill, irrespective of the fulfilment or non-fulfilment of their right to access to health care and essential medicines. Furthermore, factors such as training, education and the economic climate, also play a role in a person's ability to pursue a higher level of well-being. If any one of these factors has a detrimental effect on a person's capabilities, poverty will result, irrespective of whether or not their right of access to health care and essential medicines has been fulfilled. UNHCHR Human Rights and Poverty Reduction: A Conceptual Framework 7-8; UNHCHR Human Rights Approach to Poverty Reduction Strategies guideline 7 para 114. 60 UNHCHR Human Rights and Poverty Reduction: A Conceptual Framework 3. 61 Ochoa "Poverty and Human Rights" 59. 62 Ochoa "Poverty and Human Rights" 59. The development of concepts that link poverty to a lack of rights, has led to more attention being paid to human rights-based approaches as a means to ensure basic security and poverty reduction. 74 By viewing poverty as the denial of human rights, the focus is moved away from poverty reduction as an issue exclusive to economic development towards the rights and obligations entrenched within the formal legal system. 75 In the context of human rights, poverty is thus no longer seen as a social problem but rather as an infringement on human rights, where relationships 67 See UNCESCR Poverty and the ICESCR para 13. 68 In this regard see for example aa 16, 25 and 26 of the ICCPR, a 12 of the ICESCR and a 25 of the UDHR. This link between poverty and human rights has been acknowledged and promoted by the UN by it granting the High Commissioner for Human Rights the mandate to formulate guidelines for the integration of human rights into poverty reduction strategies. 77 These guidelines acknowledge that a human rights-based approach to poverty reduction entails that policies and institutions attempting to reduce poverty are based on the norms and values of international human rights. 78 This approach links poverty reduction to rights and obligations.
The eighteen guidelines can be divided into three sections: section one sets out the basic principles that need to be considered when formulating poverty reduction strategies in terms of a human rights-based approach. 79 Section two sets out the human rights approach according to which the content of a poverty reduction strategy can be determined. 80 In this section, the main elements that ought to be included into strategies aimed at fulfilling each human right relevant to poverty reduction are identified. 81 Lastly, section three explains how the human rights approach can lead to monitoring and accountability as aspects of poverty reduction strategies. 82 There is no doubt that these guidelines address complex issues which are of the utmost importance for the relationship between poverty and human rights.  83 Including the right to health. Mubangizi 2005 SAJHR 38; UNHCHR Human Rights Approach to Poverty Reduction Strategies para 42. Access to essential medicines as an element of the right to health

The ICESCR
Article 12 of the ICESCR is considered the most important international law provision relating to the right to health. 84 The rights contained in this document have been the subject of several high-profile and authoritative attempts at norm clarification. 85 The UNCESCR, in General Comment 14 86 on the content of the right to health as enshrined in article 12 of the ICESCR, emphasises that the phrase "right to health" should not be read as implying a right to be healthy, since one's health status is influenced by various personal and environmental factors. Instead, the right may best be understood as encompassing a package of interrelated and mutually supporting rights that operate jointly to enable the achievement of the highest attainable standard of physical and mental health. 87 While article 12(1) 88 of the ICESCR provides a broad formulation of the right to health in international law, article 12(2) 89 proceeds to prescribe a non-exhaustive list of steps to be taken in pursuit of the highest attainable standard of physical and mental health. 90 It is article 12(2), in particular, that illustrates how medication comes into play in the right of access to healthcare. 91 84 Alston 1998 ESR Review 2; Pieterse Benefit-Focused Analysis of Constitutional Health Rights 26. 85 For instance the Limburg Principles on the Implementation of the ICESCR (1987)  General Comment 14 paras 1, 3-4, 7-9. See also Bueno de Mesquita, Hunt and Khosla International Assistance and Cooperation in Health 114. 88 Article 12(1) of the ICESCR provides that "[t]he States Parties…recognise the right of everyone to the enjoyment of the highest attainable standard of physical and mental health". The first of these rights, as contained in article 12(2)(a), can be interpreted as a right to adequate maternal, child and reproductive health services and information.
This right entitles pregnant women and new-born children to the context-specific care necessitated by their particular health-related vulnerabilities. 92 The right of access to anti-retroviral drugs to prevent MTCT of HIV can, for example, be seen as a constituent element of this right.
Article 12(2)(b) implies two broad entitlements, firstly, a right to occupational health, safety and hygiene 93 and secondly a right to environmental determinants of health. 94 Of particular importance to the topic at hand are subarticles 12(2)(c) and 12(2)(d).
Article 12(2)(c) implies the right to the prevention, treatment and control of epidemic, endemic, occupational and other diseases. 95 The right requires the establishment of prevention and education programmes for behaviour-related health concerns such as sexually transmitted diseases, in particular HIV/AIDS, the creation of a system of urgent medical care in cases of accidents, epidemics and similar health hazards, and the provision of disaster and humanitarian relief in emergency situations. The control of diseases refers to States' individual and joint efforts inter alia to implement or enhance immunisation programmes. 96 The reference to 92 This right may, according to Pieterse Benefit-Focused Analysis of Constitutional Health Rights 31 be further justified by virtue of the fact that such access is essential for the achievement of substantive gender equality. 93 General Comment 14 para 15. This right includes the right to the improvement of all aspects of environmental and industrial hygiene, inter alia "preventive measures in respect of occupational accidents and diseases; the requirement to ensure an adequate supply of safe and potable water and basic sanitation; the prevention and reduction of the population's exposure to harmful substances such as radiation and harmful chemicals or other detrimental environmental conditions that directly or indirectly impact upon human health" and "the minimisation, so far as reasonably practicable, of the causes of health hazards inherent in the working environment". 94 General Comment 14 para 15. Such environmental determinants of health include "adequate housing and safe and hygienic working conditions, an adequate supply of food and proper nutrition, and [discouragement of] the abuse of alcohol, and the use of tobacco, drugs and other harmful substances". These environmental determinants of the right to health are important in relation to access to medicines too. In relation to the HIV/AIDS pandemic, for example, access to medicines alone has been proven insufficient to ensure good health. Access to adequate nutrition is also critical to the success of anti-retrovirals in reducing MTCT of the virus. See Chirwa 2003 SAJHR 547. 95 General Comment 14 para 16. 96 General Comment 14 para 16. A 12(2)(c) of the ICESCR further encompasses the promotion of social determinants of good health such as environmental safety, education, economic development and gender equity. Disease control further encompasses making available relevant treatment presupposes an obligation to take measures aimed at ensuring access to medicines. 97 This right can be interpreted to include the right of access to certain medicines, namely medicines necessary for immunisation and medicines specifically required to combat particular epidemics (such as anti-retrovirals which, although they do not combat the epidemic, are essential in the management and control thereof).
Probably the most important of the rights in the ICESCR relating to access to medicines is contained in article 12(2)(d), which implies the right to have access to health care facilities, goods and services. 98 General Comment 14 understands this article to require "the provision of equal and timely access to basic preventative, curative, rehabilitative health services and health education; regular screening programmes; appropriate treatment of prevalent diseases, illnesses, injuries and disabilities, preferably at community level; the provision of essential drugs; and appropriate mental health treatment and care". 99 By explicitly including "the provision of essential drugs" as a component of this right, the CESCR underlines the importance of access to medicines (at the very least, essential medicines) as one of the components of the right to health. The WHO estimates that about one-third of the world's population lacks access to essential medicine 100 and that the HIV/AIDS pandemic has worsened this problem. 101 Although there is currently no cure for HIV/AIDS, anti-retrovirals have proven to be effective in reducing AIDS-related death rates in high-income countries. Access to medication, treatment and care is technologies, using and improving epidemiological surveillance and data collection on a disaggregated basis. 97 According to Hestermeyer Human Rights and the WTO 104, prevention, treatment and control of most diseases rely on medicine as an integral, vital and indispensable part of the therapy. The treatment of serious infections without antibiotics, of fungal infections without antifungal agents, and increasingly, of viral infections without viral agents is unthinkable and could even constitute malpractice. Access to medicine is thus necessary for the prevention and treatment of most diseases as well as the control of communicable diseases. Medical service and medical attention thus an essential element of an effective response to such pandemics. It is also critical in respecting the rights of those affected. 102

Essential medicines
The first attempt at defining "essential drugs" was made in 1977 by the Expert Committee on the Selection of Essential Medicines, 103 which defined essential drugs as those drugs that "are of the utmost importance, basic, indispensable and necessary for the health needs of the population". 104 The Expert Committee then, without motivation, amended this definition by describing essential medicines as "those that satisfy the needs of the majority of the population; they should therefore be available at all times in adequate amounts in appropriate dosage forms". 105 All subsequent Committees endorsed this definition until 1999 when the element of affordability was incorporated. 106 According to this definition, therefore, essential medicines had not only to satisfy the health care needs of the majority of the population and be available in adequate amounts and appropriate dosage forms, but they also had to be available "at a price that individuals and the community [could] afford". 107 This 1983 definition, as revised in 1999, raises several concerns. Firstly, what is meant by the phrase the "majority of the population" is unclear. Secondly, although 102 Whereas AIDS is almost 100% terminal if left untreated, anti-retroviral treatment may convert it into a chronic yet controllable disease similar to diabetes or high blood pressure. While these drugs have been widely available in the United States, they have because of their cost been out The WHO Committee on the Selection and Use of Essential Medicines is a committee comprised of international experts that provide the WHO with scientific and technical advice. They serve without remuneration in their personal capacities rather than as representatives of governments or other bodies and their views do not necessarily reflect the decisions or stated policy of the WHO. The Committee meets every two years to review the latest scientific evidence on the efficacy, safety and cost effectiveness of medicines in order to revise and update the WHO Model List of Essential Medicines for both adults and children. the elements of availability and accessibility are included in the definition, those of adequate quality and acceptability are omitted. 108 In recognition of these concerns the WHO has adopted a new definition of the term "essential medicines", comprising three components, namely, definition, selection criteria and purpose. Essential medicines are, according to this definition, medicines that satisfy the priority health care needs of the population. 109 Such medicines are selected "with due regard to disease prevalence, evidence on efficacy and safety, and comparative costeffectiveness" and the purpose of these medicines is that they should be "available within the functioning health systems at all times in adequate amounts, in the appropriate dosage forms, with assured quality, and at a price the individual and the community can afford". 110 Through the classification of certain drugs as essential medicines the WHO thus prioritises a limited list of vital and essential drugs that are supposed to be effective, safe, of a good quality and affordable for the treatment of the priority health care needs of the population. 111 This list is updated by the WHO every two years. 112 While the importance of the medicines listed on the WHO's Essential Drugs List 113 should not be underestimated, cognisance should be taken of the fact that many medicines that are essential to the lives of many people, for example contraceptives, which are crucial to women's health and well-being, are not included on the list.
Such exclusion should, according to Yamin,114  The requirement of accessibility has four components with which health facilities, goods and services must comply, namely non-discrimination, physical accessibility, economic accessibility and information accessibility. 118 The elements of nondiscrimination and physical accessibility both require that the health-care goods and services (for purposes of this topic, medicines) must be accessible to all, especially vulnerable and marginalised groups, including persons with HIV/AIDS. 119 Information accessibility includes the right to seek, receive and impart information concerning health issues but should not impair the right to have personal health data treated with confidentiality. 120 Economic accessibility, or affordability, deals with the issue of drug pricing. 121 This element requires that health facilities, goods and services must be affordable to all, including socially disadvantaged groups. According to General Comment 14, equity 115 General Comment 14 para 12. See Pieterse Benefit-Focused Analysis of Constitutional Health Rights 33. 116 General Comment 14 para 12(a).

117
Other health-care facilities, goods and services and programmes identified by General Comment 14 para 12 include the underlying determinants of health, such as safe and potable drinking water and adequate sanitation facilities, hospitals, clinics and other health-related buildings, trained medical and professional personnel receiving domestically competitive salaries. 118 General Comment 14 para 12(b)(i)-(iv). 119 Other groups listed as vulnerable or marginalised include ethnic minorities and indigenous populations, women, children, adolescents, older persons and persons with disabilities. See General Comment 14 para 12(b)(ii). 120 General Comment 14 para 12 (b)(iv). 121 Hestermeyer Human Rights and the WTO 105. demands that poorer households should not be disproportionately burdened with health expenses as compared to richer households. 122 While primary medical care (including the first and second-line HIV/AIDS medication) is generally available free of charge or at a minimal cost in the public health sector, secondary and tertiary care (including third-generation medication, which becomes necessary once resistance has been built up against first and second-generation medication) is often not. Whether or not this infringes upon the requirement of economic accessibility is an issue of much debate.
Acceptability requires that health care facilities, goods and services are culturally appropriate 123 and adhere to relevant medical ethics and standards, 124 while the requirement of quality requires that such facilities, goods and services are "scientifically and medically appropriate and of good quality", which includes the provision of scientifically proven and unexpired drugs. 125 From the above, it is clear that the four elements of accessibility of medicine can, at times, come into conflict. 126 The requirement of appropriate quality can, for example, conflict with the requirements of accessibility and availability.

Limitations on the right of adequate access to essential medicines
The international community has recognised the reality that, due to the great extent of the prevailing socio-economic need as well as the significant resource implications 122 General Comment 14 para 12(b)(iii). 123 Here, the issue of universal as opposed to relative acceptability comes into play. In a 2012 study by Rice et al 2012 HIV/AIDS -Research and Palliative Care 79 on cultural differences in the acceptability of a vaginal microbicide, for example, it was found that the use of this a vaginal microbicide as a measure in the prevention of the transmission of HIV does not enjoy the same acceptance among African-American women in America and African women in Zambia. Despite the fact that this medical intervention meets acceptable medical standards, it was found to be less culturally appropriate among the participants in Zambia than in America for various reasons, including lack of knowledge as to the product, not having full control of their sexual health because of social demands on their accepted behaviour in a marriage setting, and low adherence to the use of the product. 124 General Comment 14 para 12 (c). 125 As well as skilled medical personnel, hospital equipment, safe and potable drinking water and adequate sanitation. General Comment 14 para 12 (2) access to medication in the context of pandemics such as HIV/AIDS is one fundamental element for achieving progressively the full realisation of the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.
General Comment 14 recognises the tripartite typology of interdependent duties with regards to the right to health. 135 According to this typology, the right to health imposes three levels of obligations on State Parties, namely the obligations to respect, protect and fulfil the right to health. 136 The duty to respect requires State Parties to refrain from interfering directly or indirectly with the enjoyment of the right to health. This duty includes but is not limited to the obligation to refrain from denying or limiting equal access for all persons to preventive, curative and palliative health services; from marketing unsafe drugs and from limiting access to contraceptives. 137 Denial of access to essential medicine or medical products would thus constitute a violation of this duty, as would any discriminatory allocation of medicines or funding for medicines. 138 The UNHRC Access to Medication in the Context of Pandemics Resolution 139 calls upon states at national level to "refrain from taking measures which would deny or limit equal access for all persons to preventive, curative or palliative pharmaceuticals or medical technologies used to treat pandemics such as HIV/AIDS or the most common opportunistic infections that accompany them".

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The duty to protect requires State Parties to take measures that prevent third parties, including pharmaceutical companies, third-party states and international institutions such as the WTO, from interfering with article 12 guarantees. 141 The importance of the duty to protect is even greater in respect of access to medicines, as pharmaceuticals are almost entirely manufactured and marketed by the private sector. 142 This places the state under an obligation to ensure that pharmaceutical manufacturers do not limit the accessibility of essential drugs. 143 The duty to fulfil, which encompasses the duty to promote, entails an obligation to act positively in facilitating the actual realisation of the right to health. 144 According to General Comment 14, this duty requires State Parties to adopt appropriate legislative, administrative, budgetary, judicial, promotional and other measures towards the full realisation of the right to health. This duty places obligations on States Parties which include, but are not limited to, giving sufficient recognition to the right to health in the national political and legal systems, preferably by way of legislative implementation; adopting a national health policy with a detailed plan for realising the right to health (including a policy on generics); 145 ensuring the provision of health care, including immunisation programmes against major infectious diseases; and providing a public, private or mixed health insurance system which is affordable for all. 146 Additionally, the duty to fulfil includes an obligation to provide the right when individuals or groups are unable to realise the right by their own means. 147  Where a state acquires the drugs for the patients or contributes to a comprehensive health insurance system that provides the drugs to all patients who need them, high prices do not limit economic accessibility. However, even developed nations are finding it increasingly difficult to finance such a system. See Hestermeyer Human Rights and the WTO 109. As is evident from the above article, the "minimum core approach" to socioeconomic rights serves not only to clarify the content of these rights but also to prioritise certain basic needs over others (indicating a starting point and general framework for progressive realisation). 152 While General Comment 3 provides that the resources of a particular State Party must be taken into account in determining whether or not it has met its minimum core obligations, it requires that states give priority to the meeting of people's basic needs. 153 The minimum core approach, which is aimed at protecting the most vulnerable members of society, entails that there are minimum levels of socio-economic subsistence below which nobody should be allowed to exist regardless of state-resource constraints. This approach aims to identify such subsistence levels, which represent a "floor" of immediately enforceable entitlements from which progressive realisation should proceed. 154 It does not require the division of rights according to their priority, but rather that each right be realised to the extent that provides for the basic needs of everyone. 155 Failure to meet these basic standards for a dignified human existence prima facie amounts to a breach of the obligations of the ICESCR. 156 Only when a state can convincingly show that resources are "demonstrably inadequate" can its failure to fulfil these duties be justified. 157 Such a minimum threshold is, however, country specific. In other words, the ways in which economic and social rights can be realised will vary with the nature of the national situation and the conditions applying there. 158 The CESCR has, however, indicated that a state party is still under the obligation to strive to ensure the widest possible enjoyment of the relevant rights under the prevailing circumstances. 159 In relying on a lack of available resources as a defence for not meeting such a minimum core, states must demonstrate that they have made every effort to use all of the resources at their disposition in an effort to satisfy, as a matter of priority, those minimum obligations. 160  A state which fails to satisfy such obligations is placed under an increased justificatory burden to demonstrate that every effort has been made to make use of all resources available to it to satisfy, as a matter of priority, these minimum core obligations. General Comment 3 para 10. See Hestermeyer Human Rights and the WTO 220; Mbazira Litigating Socio-Economic Rights 61; Yamin 2003 B U Int'l LJ 358. rights enunciated in the Covenant, including essential primary health care, and refers to the Alma-Ata Declaration 162 to provide guidance on the core obligations arising from article 12. These core obligations include inter alia the obligation to ensure the right of access to health facilities, goods and services on a non-discriminatory basis, especially for vulnerable or marginalised groups; 163 to provide essential drugs, as from time to time defined under the WHO Action Programme on Essential Drugs; 164 to ensure equitable distribution of all health facilities, goods and services; 165 to adopt and implement a national public health strategy and plan of action, on the basis of epidemiological evidence, addressing the health concerns of the whole population; 166 to ensure reproductive, maternal (pre-natal as well as post-natal) and child health care; 167 to provide immunisation against the major infectious diseases occurring in the community; 168 and to take measures to prevent, treat and control epidemic and endemic diseases. 169

4
The role of access to essential medicines in poverty reduction According to Thekaekara,170 poverty can be alleviated only if there is an even and rapid spread of healthcare. The link between poverty and health is clear when one considers that the poor are generally not as healthy as the rich and that people in lower social classes are more prone to contracting infectious deceases. 171 This is especially true for third-world countries, where the HIV/AIDS pandemic makes the impoverished more prone to contracting HIV-related illnesses such as tuberculosis.
Furthermore, ill health not only causes poverty but also contributes to it by destroying livelihoods, reducing productivity and educational achievements and 162 Alma-Ata Declaration (1978)  limiting opportunities. 172 The adequate fulfilment of these peoples' right of access to essential medicines will inevitably enable them to achieve a higher level of wellbeing, thereby reducing the level of poverty experienced. However, as poverty leads to an increased exposure to environmental risks, malnutrition and ill health due to a reduction in access to health care and essential medicines and a lack amongst other goods of sufficient food, clean drinking water and housing, ill health is also considered to be a consequence of poverty. 173 Despite the fact that ill health is considered to be both a cause and a consequence of poverty, access to health care and essential medicines is still deemed a key element in achieving good health, enabling the impoverished to achieve a higher level of well-being through an increased livelihood, ultimately resulting in a reduction of poverty. 174 As good health can contribute to economic security by safeguarding other rights such as the right to education and the right to work, the UN accordingly holds good health as essential for the creation and sustainability of those basic capabilities needed to escape the vicious cycle of poverty. 175 Thus, the right of access to health care and essential medicines has a crucial role to play in poverty reduction strategies. Guideline number seven sets out the following targets for the fulfilment of the right to health as part of a poverty reduction access to health care. Adequate access to essential medicines plays a role in each of these targets.
The UN has also identified some key features for the fulfilment of the right to health as part of a poverty reduction strategy. 177 Amongst these is the obligation on states to improve the provision of and access to personal health services for those who live in poverty. This can be done by targeting service delivery to the poor and by ensuring that the division of resources favours poorer geographical areas. By ensuring that the division of resources favours primary health care which respects culture and gender and is of a good quality, access to these services will inevitably also improve. Essential medicines as prescribed by the WHO must be provided, prioritising reproductive and mother-and-child health care. Illnesses that specifically impact on the poor, like malaria, tuberculosis and HIV/AIDS, must be identified and programmes must be specifically developed and launched to help the poor. 178 Furthermore, states must reduce the financial burden placed by health care and health protection on the poor by reducing or removing user fees, for instance. 179 In order to eradicate poverty and promote human dignity and equality, the

Conclusion
The human rights-based approach to poverty defines poverty as the inadequate fulfilment of a person's human right to basic capabilities, an approach which interprets poverty, very broadly, as the absence of the capabilities needed to live a dignified life. 187 As such, poverty constitutes an infringement on human rights 188 and will not be eradicated without the fulfilment of human rights, including the right to health. 189 The most important international law provision relating to the right to health is article 12 of the ICESCR. Article 12(1) of this document provides a broad formulation of the right to health in international law, while article 12(2) prescribes a non- health. 190 Article 12(2), in particular, illustrates the role that adequate access to medication plays in the right of access to healthcare. 191 The CESCR, has explicitly included the provision of essential drugs as a component of the right to healthcare, 192 thereby emphasising the causal link between the lack of access to essential medicines and the non-fulfilment of the right of access to healthcare. 193 As with all socio-economic rights, the resource implications of the realisation of the right to health are such that states cannot be expected to immediately comply with their obligations in respect thereof. 194 Instead, article 2(1) of the ICESCR and the General Comments of the CESCR place obligations on states to take deliberate, concrete and targeted steps towards expeditious and effective full realisation of the right to health, including access to medication. 195 The measures taken to do so must, according to General Comment 3, embrace the concept of the minimum core obligation (the minimum core in relation to medicines being access to essential medicines, at the very least). 196 The spread of access to healthcare will, as is illustrated by the graph above, contribute to poverty reduction. The adequate fulfilment of peoples' rights of adequate access to essential medicines will enable them to achieve a higher level of well-being, thereby reducing the level of poverty which they experience. 197 Both the right to access healthcare and the right to access essential medicines -the latter