Drs Rathore and Mansoor raised several important issues when considering pressure ulcer (PU) in spinal cord-injured patients. We would like to propose the following comments.

Following spinal cord injury (SCI), the most common complication in many developing countries is PU.1, 2 To prevent PU, one of the main barriers is its resources including costs of health service and distribution of health-care centers across the country. Another barrier is service setting in our country, which is the focus of this letter because of the importance and inattention in this issue.

The current service offered to patients in Iran is the ‘Fee for Service’ system in which the health service would be available for anybody who refers to health-care centers. It means that the health-care providers have no responsibility for those who do not refer.

We believe that ignoring the health of patients who do not refer to health centers causes these missing SCI patients to present with PU and numerous other problems. With the unwillingness from practitioners to treat patients from low socioeconomic levels, the current health-service setting of our country encourages the feeling of ‘helplessness’ among these patients, for example, a quadriplegic patient with low income. In the current system, no one is responsible for the health guarantee of patients who are out-of-reach, and because of no surveillance, the poor health control will lead to PU and other complications.

As a solution, we need a health-system reform and a health-oriented approach and not a treatment-oriented package for SCI patients.

Also, we would greatly recommend national SCI data registry and collaboration with EMRO countries and would cooperate with such projects on SCI in the EMRO region.