sections of the population, especially vulnerable or marginalized groups, such as ethnic minorities and indigenous populations, women, children, adolescents, older persons, persons with disabilities and persons with HIV/AIDS. Accessibility also implies that medical services and underlying determinants of health, such as safe and potable water and adequate sanitation facilities, are within safe physical reach, including in rural areas. Accessibility further includes adequate access to buildings for persons with disabilities […] iii) Economic accessibility (affordability): health facilities, goods and services must be affordable for all. Payment for healthcare services, as well as services related to the underlying determinants of health, has to be based on the principle of equity, ensuring that these services, whether privately or publicly provided, are affordable for all, including socially disadvantaged groups. Equity demands that poorer households should not be disproportionately burdened with health expenses as compared to richer households; […]. c) Acceptability. All health facilities, goods and services must be respectful of medical ethics and culturally appropriate, i.e. respectful of the culture of individuals, minorities, peoples and communities, sensitive to gender and life-cycle requirements, as well as being designed to respect confidentiality and improve the health status of those concerned. d) Quality. As well as being culturally acceptable, health facilities, goods and services must also be scientifically and medically appropriate and of good quality. This requires, inter alia, skilled medical personnel, scientifically approved and unexpired drugs and hospital equipment, safe and potable water, and adequate sanitation.45 (Underlining added) 36. If we analyze this case from the perspective of the right to health we find that, in the first place, the availability of the right to health was affected, since the prison lacked sufficient medical staff or essential drugs to treat the victim’s frail health condition. In the second place, regarding accessibility, this principle was breached in two ways; on the one hand, by the problems stemming from the bureaucratic procedures - de facto and de jure accessibility – involved in obtaining permission to leave prison to receive medical attention and, on the other hand, by the lack of economic accessibility (affordability) of the right to health, since the lack of insulin at the COF made it necessary for the victim and her family to supply that medication; in third place, regarding the acceptability of the right to health, far from improving Mrs. Chinchilla’s state of health, the lack of medical treatment aggravated her situation within the COF; and, finally, regarding the quality of the right to health, the COF did not have appropriate health facilities and services to treat Mrs. Chinchilla’s diabetes. 37. It is undeniable that in the case of Mrs. Chinchilla Sandoval the right to health was involved in a manner that was palpable and autonomous, in the face of the deficient medical treatment provided at the COF. The lack of available, accessible, acceptable and quality medical attention, was decisive inasmuch as it resulted in the amputation of her leg, creating a situation of disability, since the failure to provide her with adequate medication or a diet suited to her needs led to a deterioration in her health over time. In this case, the State violated several aspects of the right to enjoy the highest attainable standard of health by not preventing the diabetes from further aggravating the conditions in which Mrs. Chinchilla served her sentence. 38. The right to health, as conceived in the San Salvador Protocol and in the International Covenant on Economic, Social and Cultural Rights, implies prevention and treatment of Committee on Economic, Social and Cultural Rights, General Comment 14, The Right to the Highest Attainable Standard of Health (Article 12 of the International Covenant on Economic, Social and Cultural Rights), (Twenty-second Session, 2000), U.N. Doc. E/C.12/2000/4 (2000), para. 12. 45 14