High death rates result from a combination of an ageing population, a high number of people at risk of poverty and a weak healthcare system. More than 80% of all deaths are due to cancer and cardiovascular conditions; nearly a fifth of those are avoidable. Although healthcare in Bulgaria is nominally universal, out-of-pocket expenses account for nearly half of all healthcare spending, which significantly limits access to medical care. Other problems disrupting care provision are the emigration of doctors due to low wages, understaffed and under-equipped regional hospitals, supply shortages and frequent changes to the basic service package for those insured. The 2018 Bloomberg Health Care Efficiency Index ranked Bulgaria last out of 56 countries. Average life expectancy is 74.8 years compared with an EU average of 80.99 and a world average of 72.38.