Unconventional validity

8 December 2020

One long-underestimated health resource is traditional and complementary medicine (T&CM), which comes with numerous practical applications. As products and as medically verified treatments, T&CMs have been on a long journey to legitimacy, though threats – such as Covid-19 – continue to threaten derailment, even as WHO is beginning to look encouraging at them. Martin Morris dissects the latest WHO-based research on the topic.

When it comes to the prevention or management of lifestyle-related chronic diseases, as well as its potential positive impact on ageing populations, traditional medicine can prove useful in fighting various ailments. Within this field are botanical dietary supplements – also referred to as herbals or herbal dietary supplements, for example products manufactured from plants, plant parts or plant extracts. Against this backdrop, consumer expectations for care are increasing. Factor in rising public costs, budgets that are often either stagnant or being cut in real terms – despite countries looking to expand their healthcare systems in the longer term – and it should come as no surprise that the traditional and complementary medicines (T&CMs) market is seeing significant traction. WHO flagged as much in its 2019 ‘Global report on traditional and complementary medicine’, arguing that improving equitable access to safe, high-quality and effective T&CM services can potentially meet communities’ needs, and build sustainable and culturally sensitive primary healthcare.

Indeed, the Astana Declaration, adopted at the Global Conference on Primary Healthcare in October 2018, stated that the success of primary healthcare “will be driven by applying scientific as well as traditional knowledge, and extending access to a range of healthcare services, which include traditional medicines”.

In the same year, the infrastructure on the governance of T&CM at national level had already been significantly improved, with 107 member states of WHO confirming a national office for T&CM, and 75 a national research institute.

In the meantime, 34 member states across the six WHO regions included traditional or herbal medicines in their national essential medicines lists, while many, such as Ghana, had a separate list of essential herbal medicines.

In the US, as well as elsewhere, supplements have had to jump through a number of hoops to meet regulatory requirements – more specifically, under the Dietary Supplement Health and Education Act (1994) in the US – before they can be classified as ‘dietary supplements’.

Beyond an obvious intention to supplement the diet, they must also include one or more dietary ingredients, including vitamins, minerals, herbs or other botanicals; an intention that the supplement is delivered by mouth as a pill or capsule; and that labelling on the front panel makes clear it’s a dietary supplement. It is worth noting that, in the US, an Office of Alternative Medicine was formed within the National Institutes of Health (NIH) Office of the Director in 1992, while in 1999, the National Centre for Complementary and Integrative Health (NCCIH) was set up.

Europe mirrors the US

Meanwhile in Europe, the European Food Safety Authority (EFSA)’s Directive 2002/46/EC has been designed, like its US counterpart, to shield consumers from potential health or misinformation risks posed by some supplements, as well as giving specific guidance for permitted vitamins and minerals.

The key takeaway, however, is that legislation has historically been framed in response to a backdrop where consumer behaviour has been changing. Indeed, greater consumer spending power (as incomes rise) has led to changes in purchasing habits given health, fitness and wellness have been drivers in the food nutritional supplements market and related food products.

In short, when it comes to health, prevention is increasingly being seen as better than cure. In addition, natural commodities are increasingly viewed as healthier and eco-friendlier, meaning consumers are more likely to add food nutrients to their daily diet, even if it means taking more pills and liquids. Sustainability is also becoming an increasingly important issue, especially in European countries and North America, where, from both a consumer and buyer perspective, customers are increasingly wanting to know where products are being sourced from.

But, sustainable or not, manufacturers have been quick in responding to changing consumer habits, increasing the number, range and variety of products available on the open market, and providing greater ease of access to food supplements as they widen applications and introduce new product portfolios to capture domestic and international markets.

An indicator of this changing landscape can be seen in a November 2018 report from Grand View Research. Valuing the global herbal supplements market in 2017 at an estimated $5.26bn, the research company also forecasts growth at a CAGR of 6.2% through to 2025.

One of the key factors contributing to this growth, according to the report, is a rising inclination towards natural products among consumers, increased awareness regarding preventive healthcare, and a surge in spending on health and wellness. Noteworthy too has been a growing geriatric population, against a backdrop of increased incidences of chronic health conditions, which have been fuelling demand for herbal products across the globe.

The 2017 value of the global herbal supplements market.
Grand View Research

Sure to grow

Meanwhile, Mordor Intelligence’s 2019 report – ‘Dietary supplements market – growth, trends and forecast (2020–2025)’ – paints an even rosier picture, forecasting the global botanical supplements market to grow at a CAGR of 7.3% over the 2020–2025 period, with future growth of supplements expected to skew in the favour of botanicals. The study pointed out that the perceived health benefits of herbal supplements “are very well established among millennials across both developing as well as developed economies”. Hence, it is a demographic that is likely to be a major target for herbal and botanical supplement companies.

On the downside, Mordor noted, lack of stringent norms and regulations relating to the safety and efficacy of botanical health supplement products “is a factor expected to restrain the growth of the market globally”.

The CAGR growth forecast of the global herbal supplements market by Grand View Research up to 2025.
Grand View Research

Meanwhile, WHO is now two-thirds of the way through its ‘Traditional medicine strategy 2014–2023’, a T&CM report noting the focus that is now being put on developing “norms, standards and technical documents – based on reliable information and data”.

One of the major objectives of this strategy is, “To build the knowledge base for active management of T&CM through appropriate national policies.” As a result, a key priority identified for member states has been the strategic gathering, analysis and synthesis of data on T&CM use, and the development of a national research agenda.

The CAGR growth forecast of the global herbal supplements market over the 2020–2025 period.
Mordor Intelligence

Another has been to promote universal health coverage by integrating T&CM services into healthcare service delivery and self-health – with the potential contribution of T&CM to improve both health services and health outcomes.

“In an ideal world, traditional medicine would be an option offered by a well-functioning, people-centred health system that balances curative services with preventive care.” Tedros Adhanom Ghebreyesus, WHO

In 2018, 98 member states (of 179 reporting) had developed national policies on T&CM, 109 had launched national laws or regulations on T&CM and 124 had implemented regulations on herbal medicines, as a growing number of states recognised the role of T&CM in their national health systems.

Drill down through the data though and lack of regulation, as well as lack of political will, have continued to act as impediments.

Indeed, the lack of capacity to monitor the safety of T&CM products, referral mechanisms between T&CM and conventional medical practitioners, information systems and analysis of T&CM, as well as the integration of T&CM into health systems, has proven to be an obstacle. The complexity of regulations, for example, can be seen in Europe where seemingly identical valerian (flower) endproducts may come under different regulatory regimes – depending on whether they’re being marketed as a medicinal product or a food supplement – the ultimate determination being on how the product has been manufactured. For the consumer, though, little insight is ever provided in terms of these differing manufacturing processes.

Clever accounting

Manufacturers have increasingly shifted botanical products registered as medicines over to food supplements. This is not surprising given the regulatory regime governing food supplements is usually less onerous and provides greater flexibility for them. Any health property claim, for example, would need to be supported by at least two doubleblind placebo-controlled clinical studies.

In the meantime, as WHO continues to argue, countries looking to integrate the best of T&CM and conventional medicine would do well to look less at the many differences between the two systems, and instead at areas where both converge. This is to help tackle the unique health challenges of the 21st century.

“In an ideal world,” WHO director-general Tedros Adhanom Ghebreyesus wrote in the 2019 report’s foreword, “traditional medicine would be an option offered by a well-functioning, people-centred health system that balances curative services with preventive care.”

The elephant in the room, though, remains the long-term impact of Covid-19. Early on in the pandemic, companies found it increasingly difficult to distribute their products to consumers due to supply chain disruptions caused by lockdowns implemented across the globe. Demand for dietary supplements containing vitamins C and D, for example, has risen because they’re increasingly being seen as affording a safe low-cost and effective means of preventively helping the immune system fight off the ravages of Covid-19 and associated respiratory tract diseases.

The bigger (and unanswered) question is whether the second wave of Covid-19 – again hitting Europe with a vengeance at time of writing – will lead to further supply chain disruptions down the road as authorities reinstitute lockdowns (to varying degrees) in response.

Hence, demand for products may count for less if it becomes increasingly difficult to get some of those products to market. Especially, if the recent global economic recovery – post the initial lockdown shock – goes into reverse. This may act as a restraint in the medium term at least.

All market predictions for herbal supplements suggest it will skyrocket.

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