When Karen Papiyants lost his leg in a road accident last year, his medical nightmare was only beginning.

Although like any Russian he was entitled to free treatment, he says the doctors strongly suggested he pay $4,500 into their St. Petersburg hospital's bank account, or be deprived proper care — and perhaps not even survive.

Faced with that choice, the 37-year-old truck driver's relatives scrambled to scrape together the money. But Papiyants said that didn't stop the nursing staff from leaving him unattended for most of the night and giving him painkillers only after he screamed in agony.

"It's nothing but blackmail and extortion on the part of doctors," Papiyants said.

In theory Russians are supposed to receive free basic medical care. But patients and experts say doctors, nurses and surgeons routinely demand payments — even bribes — from those they treat. And critics say the practice persists despite Russia's booming economy and its decision to spend billions to improve the health care system.

Medical care in Russia is among the worst in the industrialized world. A 2000 World Health Organization report ranked Russia's health system 130th out of 191 countries, on a par with nations such as Peru and Honduras.

This is one of the few nations in the world where life expectancy has declined sharply in the past 15 years. The average Russian can expect to live only to age 66 — at least a decade less than in most Western democracies, according to a 2005 World Bank report. For men, the figure is closer to 59 — meaning many Russian men don't live long enough to start collecting their pension at age 60.

Compounded by alcoholism, heart disease claims proportionately more lives than in most of the rest of the world. Death rates from homicide, suicide, auto accidents and cancer are also especially high.

Russia's population has dropped precipitously in the past 15 years, to below 143 million in what President Vladimir Putin calls "the most acute problem of contemporary Russia."

In 2004, according to the Organization for Economic Cooperation and Development, Russia spent $441 per capita on health care, about a fifth of what the Europeans spend. Over the past two years the government has more than doubled health care spending to some $7 billion, but that still works out to only about 3.4 percent of all government spending, and the World Health Organization recommends at least 5 percent.

Experts here say new spending does little if it fails to tackle corruption.

The state covers all Russians under a standardized medical insurance package, while well-heeled citizens can buy extra insurance and be treated privately.

In the Soviet era, patients occasionally rewarded doctors with money or gifts, but were largely guaranteed free treatment. The Soviet Union's public health system was, for a time at least, considered among the world's best.

But the system failed to keep up with Western medicine, and after the Soviet collapse, went into decline. Today, many who can't afford to pay or bribe — especially those in remote provinces — may never receive proper care.

Some experts say this has helped drive up death rates.

"Corruption in health care is a threat to Russia's national security in the broadest sense of the word," said Yelena Panfilova, head the Russian branch of Transparency International, a global corruption watchdog.

According to a summer 2006 study commissioned by the group, 13 percent of 1,502 respondents who had sought medical help during the previous year had to pay an average of $90 under the table, out of wages averaging $480 a month. The poll had a margin of error of 2.6 percentage points.

Panfilova also said medical and pharmaceutical companies routinely bribe health officials so that hospitals buy their equipment and medicines, even though their quality is often not the best.

Kirill Danishevsky, a health researcher with the Russian Academy of Sciences' Open Health Institute, has estimated that up to 35 percent of money spent on health care consists of under-the-table payments.

At the Dzhanelidze Emergencies Institute where Papiyants was treated, spokesman Vadim Stozharov denied that doctors refused to provide free care. But he conceded the hospital has received so many similar complaints it set up a hot line to deal with them.

The Health Ministry declined to comment on the bribery allegations. But Galina Lavrishcheva, the top health official in Stupino, an industrial town in the Moscow region, acknowledged that health care workers sometimes demand payoffs.

"Yes, it is true, I am not going to hide it — extortion takes place," Lavrishcheva said.

The Stupino regional hospital is at the forefront of government reform efforts. Officials have fought overcrowding by cutting the number of beds from 800 to 625, have set up an outpatient clinic and have installed new equipment, including ultrasound and electrocardiogram machines.

Overspecialization, a legacy of the Soviet era, is a big problem because patients are shuttled from one narrowly focused specialist to another. Meanwhile, no physician generally takes responsibility for their state of health.

Dozens of Stupino's specialists have been retrained as general practitioners and their salaries raised to reduce the lure of bribes and create incentives for more doctors to become GPs.

Yelena Filippova, a freshly retrained GP, now treats some 2,000 patients and earns $700 a month, more than double her previous salary. Filippova, 27, says the system is more efficient. Her patients like it as well.

"It's professional, it's high quality, it's quick and convenient — you don't have to stand in lines," said Viktor Lenok, a 60-year-old retiree, whom Filippova treats for asthma.

But critics say these changes are no substitute for radical change — just a high-profile way of spending the country's oil-driven wealth in an election year. They insist the reform does not address bribe-taking by emergency health care providers and medical specialists.

"A huge heap of money is being pumped into the same health care system — but why invest into something that doesn't work?" said health researcher Danishevsky. "The very system needs to be reformed."