[tcas]

Nope. You can login with a different region's iTunes account (e.g. with a US address) however and download it without a VPN.

You need a billing address/CC/PayPal in that region though, so you can't just simply register a new account and access it without basic validation.

[Canada]

That has started failing with iPhone. Now you need that and you need need a VPN. I haven't looked into why yet.

Outside of China you can just choose US as your region and it's fine.