Different Cultures, Different Products, Different RulesDifferent Cultures, Different Products, Different Rules

Despite little hard data, insiders see a growing global opportunity for supplements sold or prescribed by licensed practitioners. Beyond complementary and alternative practitioners, more classically trained physicians are realizing allopathic medical tools are not working well for many chronic health issues. Developed societies face demographic and economic healthcare challenges and practitioners seek new sources of income.
That’s the recipe for success, but success comes in different forms around the globe. Regulations and healthcare frameworks, as well as cultural and medical philosophies, vary significantly across borders. Companies need to assess their goals and be prepared for time- and resource-intensive efforts specific to each country they enter.
No size fits all
Market watchers say the global practitioner channel could be a crucial piece in the evolution of the supplement industry. “I think the reason we are even discussing the subject is the realization that there is an advantage for holistic medicine practitioners who address the cause for a condition—whether it be biochemical, genetic, lifestyle or diet. It shows our industry is transitioning from a Wild West show and a silver bullet supplement approach to more synergistic ingredients,” says Gary Brenner, founder of Brenner Pharma/Food in Hatzor-Ashdod, Israel.
Exporting supplements globally is a complicated proposition at best, and marketing products to licensed practitioners adds another layer of complexity. Thorne Research, Metagenics and a small handful of other professional brands are a few companies developing a global strategy for the channel. This strategy requires a presence in each market and a deep understanding of its culture, regulatory framework and export processes, according to Annie Niou Vonheim, SVP International for Thorne, a leading practitioner brand marketing products in multiple countries. “It takes a custom approach in each country. A good business will probably establish a foothold in their home market first,” she says. “If they are satisfied with their current market share, it might be time to consider expanding into certain international markets by exploring the low-hanging fruit first.”
That move has as much to do with corporate resources as regulatory requirements. Used to the relaxed U.S. market, companies selling to practitioners domestically might feel a rude awakening elsewhere. “There is no one market that works great for all companies,” says Vonheim. “It really depends on the core competencies in a company.”
For example, speaking Mandarin Chinese allows Vonheim to work effectively in Asian countries, but even with a native language speaker, it’s important to have someone on the ground. “If you don’t have a regular presence there,” says Vonheim, “they can forget about your brand quite easily.”
Remember the pharmacist
Companies must understand the medical philosophy in the region and invest in cultivating strong practitioner relationships. First steps might be markets where culture, medical philosophy and/or language are a good fit for the products. This leaves the door open in numerous countries, according to Brenner. “The scientific, evidence-based approach to diagnosis and treatment has its roots in individual, holistic assessments and natural treatments,” he says. “So this is not something new in Europe. And community medicine in our Israeli kibbutz movement might be considered an early version of practitioner healthcare service.”
In Israel, he adds, there is a growing number of private-label health supplements in pharmacies of major clinics as well as growing numbers of companies manufacturing private label for practitioners in Europe and Latin America. Brenner calls Brazil one of the biggest opportunities. “Brazil has several pharma companies with well-established nutraceutical brands. They will prove receptive to the practitioner concept.”
Because naturopaths and chiropractors tend to be trained in and supportive of supplements, countries with a strong base of these practitioners represent some of the best global opportunities. Kerry Cunningham, managing director of BioCeuticals, an Australia-based professional supplement line recently acquired by Blackmores, notes that BioCeuticals is a practitioner-only brand sold primarily through naturopaths, nutritionists and pharmacies—which increasingly employ in-store complementary medicine practitioners—but the line is seeing new interest from chiropractors, osteopaths and general practitioners. As Australia has one of the toughest regulatory systems, Cunningham says BioCeuticals will be well prepared to expand  practitioner-only products globally in the next year.
Countries like Canada, Australia, New Zealand and Mexico, with many of these practitioners, are good targets. “It’s not as difficult a sell as in Asia, where the concept is tougher,” says Cunningham. In China, Traditional Chinese Medicine, she adds, is not "alternative." It's regulated as medicine.
Pharmacists represent a practitioner category with potential but can be as conservative as physicians and a hard sell. In markets like Germany with homeopathic pharmacies, pharmacists are very knowledgeable about natural solutions, Vonheim says. “It’s a nice channel, but requires all the same things as working directly with doctors,” she says. “It still takes the same educational process and necessary relationships.”
Public healthcare matters
Regardless of the practitioner, the global professional supplement channel remains complex. In public healthcare systems, practitioners are restricted in what they can use and supplements are often not on the list. The channel is not growing in Japan because CAM is not widely used and CAM practitioners cannot sell supplements. Cultural pre-disposition is another issue. According to Sachiko Kakisaki, research analyst for Japan’s Global Nutrition Group, the low growth “is also related to how Japanese think about seeing doctors and pharmacists. Japanese people rely on hospitals and drugs well enough because of the universal healthcare system.” Supplements are not legally defined or supported by authorities like the Japan Medical Association and the National Institute of Health & Nutrition.
However, there are opportunities in countries where public healthcare systems don’t work well and a private practitioner segment emerges. “There are some countries where people who have the money want to avoid public healthcare,” Vonheim says. While this represents an opportunity, particularly in many Asian countries, it’s primarily the realm of doctors. It takes far more time and resources to sell supplements to them. “It can take years to develop relationships with these doctors,” she says. “It’s generally only the early adopters who first become interested, and that’s often when they come across a health problem they can’t solve with their regular tool box.”
Size isn't everything. China is a huge market, says Vonheim, but the private hospital market is small. "Out of more than 22,000 healthcare institutions, there are only a few private hospitals. So is it worthwhile? Depends on what you are trying to accomplish. If you don’t have the time and cultural understanding, it’s very difficult to succeed.”
No man’s land
Every market has its challenges. According to Steve Holmes, regulatory affairs manager for Metagenics, products must be registered in Canada and have a natural product number (NPN). However, Health Canada has numerous recognized monographs, including calcium, fish oils and probiotics. A company can apply referencing the monograph and receive an NPN much quicker. “It’s similar in Australia and the European Union, and quite different from the US,” Holmes says.
Most countries have specifications on allowed ingredients as well as RDA limits. Dosage levels are a sticking point for professional products. Some professional products are formulated using a compounding method, an acceptable practice among licensed practitioners using supplements for their own patients, notes Alicja Wojewnik, a principal at the Ontario-based consultancy Dicentra. In private practice, she says, prescribing a supplement outside established safety parameters is allowed because it is one practitioner’s opinion based on an individual patient. “But when you want to take that product and formulate it as a supplement designed to be distributed to many practitioners and eventually sold to a larger population, it’s nearly impossible from a regulatory point of view,” she says.
With the practitioner channel difficult, some companies work around regulatory challenges by registering a product for OTC. Products still need registration and pre-market evaluation, but not the scrutiny from practitioners. Placing product on pharmacy store shelves becomes a viable option. Import regulations are the same and companies don’t need to spend as much time researching potential restrictions on practitioner sales, according to Vonheim. “In many cases it might be similar to a retail product and selling it becomes a matter of advertising and promotional pushes.”
Wojewnik sees this in Canada and finds it problematic. “A product can get on the shelf and a patient can make a decision without practitioner involvement, but there is no practitioner to evaluate safety and outcomes,” she says. Companies and patients are left with this option because no appropriate regulatory category exists for something between a prescription drug and OTC. “There is no other way to introduce certain products here,” says Wojewnik. “If I were a company in that segment, I would be lobbying to create a special category.”