When Prime Minister Mark Carney told leaders at the World Economic Forum’s annual meeting in Davos that the rules-based international order is no longer functioning, he was naming a reality many policy domains have already learned the hard way. Global health confronted that breakdown early.

During COVID-19, cooperation fractured even among allies: supply chains broke, vaccine access diverged sharply across countries, and public health guidance lost authority even where resources existed. Shared threats did not reliably produce shared action. 

If rules can no longer guarantee cooperation, the systems that succeed will be those built on trust and legitimacy. In global health, lived experience leadership becomes part of core infrastructure. Global health only “works” at the point of use. When people do not trust the messenger, they do not follow the message. This plays directly to Canada’s strengths as a middle power. While middle powers rarely dictate terms, they can shape agendas and standards when they are seen as legitimate brokers and trusted partners. Canada should centre lived experience leadership in its global health strategy, demonstrate how it improves outcomes, and build coalitions around that advantage.

A system that broke before we admitted it

Well before 2020 and the COVID-19 pandemic, global health was functioning in a system where cooperation relied more on goodwill than enforceable rules. Multilateral institutions carried moral authority but little enforceable power. They could convene, but not compel. For example, COVAX was built on voluntary participation and dose-sharing; when supply tightened, many states prioritized bilateral deals and export controls over collective commitments.

However, the COVID-19 pandemic further exposed and deepened this gap. The Independent Panel on Pandemic Preparedness and Response documented how supply chains snapped, data sharing became selective, and financing surged in some places and evaporated in others. Many high-income countries secured enough vaccine doses to cover more than 200 per cent of their populations, while others struggled to access any. This pattern, often described as vaccine nationalism, undermined the legitimacy of global health institutions and made future cooperation harder to secure.

Mechanisms designed to support equitable access faltered as states prioritized national advantage, and policies that lacked legitimacy failed through poor uptake, resistance, or quiet non-compliance.

This was not a communications failure. It was a design failure.

Why “health fortresses” will not save us

It is understandable that governments are turning toward strategic autonomy in health. Domestic manufacturing, stockpiles, and export controls on critical medical products are now central to many pandemic preparedness and health security strategies. National capacity is necessary for resilience, but it is not sufficient for managing shared biological risk.

Strategies that assume borders can contain health threats offer a sense of control without guaranteeing coordination. Disease crosses borders, but so do misinformation, antimicrobial resistance, and climate-driven health disruptions. At COP30, governments and UN agencies began to outline new plans to build climate-resilient health systems and place health more firmly within the global climate agenda. Fragmented approaches can reduce vulnerability domestically while simultaneously weakening the cooperation required during crises.

The real choice is not national capacity versus global cooperation. It is between parallel systems that compete under stress and shared approaches designed to function when rules alone no longer hold. Think of it like firefighters: each country racing to grab its own water supply in a blaze, or working from a shared hydrant system everyone knows how to tap when the flames spread. The question is which system we build next. 

Why lived experience matters now

In global health, policies succeed or fail at the point of use, where real people decide whether institutions are credible. Individuals determine whether to seek care, follow guidance, share data, or trust public authorities. This is why lived experience leadership matters now — not as representation or symbolism, but as a component of system performance.

When people with lived experience are involved early in policy design, blind spots surface sooner, assumptions are stress-tested, and risks that look theoretical from the top down become visible in practice. Evidence from patient and community engagement supports this. Recent Canadian-led work in Diabetologia on “diabetes in four dialects,” for example, demonstrates how blending lived experience with research strengthens adherence and trust. A BMJ systematic review confirms the pattern: among leaders of patient involvement initiatives, 75 percent reported higher-quality health services as a result.

Canada’s quiet advantage

These shifts play to Canada’s strengths as a middle power. Canada does not possess the coercive leverage of great powers, but it retains credibility as a trusted broker, with a record of coalition-building in health, development, and human rights. Its pluralistic governance, strong public health institutions, and reputation for mediation allow it to lead through convening and coordination rather than dominance.

Canada should scale this advantage globally by embedding patient involvement at the core of health policy design, building on the Canadian Institutes of Health Research Strategy for Patient-Oriented Research, and demonstrating that inclusive governance delivers better outcomes.

What Canada is already doing differently

Canada is already embedding participation into institutional design rather than treating it as outreach. Diabetes Action Canada pays patient partners to co-lead research priorities and co-design national studies. Voices in Action Global Advocates with Diabetes, founded in Canada, organizes people with diabetes for cross-border policy input. Canada’s youth global health delegate program integrates young people’s lived experiences into World Health Assembly delegations. These are not symbolic gestures. They are governance choices that embed legitimacy into system design.

The choices that will define leadership

If Canada wants to lead in a post-rules-based global health order, the question is not whether to act, but how. Moving from values to implementation requires concrete steps. Canada should: (1) fund participation as infrastructure, treating lived experience leadership as core governance in global health initiatives with resourced agenda-setting, oversight, and evaluation roles; (2) build coalitions around shared capacity through long-term co-investment in regional manufacturing, AMR surveillance, ethical AI in health, and data stewardship, embedding affected communities; (3) embed lived experience upstream in priority-setting, negotiations, delegations, financing, and bilateral initiatives; and (4) measure leadership by uptake, trust, and community-defined success as key indicators.

Leading without nostalgia

Carney’s message in Davos was blunt: the old order is not coming back, and pretending otherwise weakens the cooperation that still exists. Global health illustrates this clearly. Its challenges are transnational, its institutions are strained, and its outcomes depend less on formal authority than on credibility and coordination.

For middle powers such as Canada, this is not a loss of influence but a change in how influence operates. Leadership increasingly comes from the ability to convene coalitions that function under pressure, invest in shared capacity, and design systems that people trust enough to follow.

Lived experience leadership is central to that task. It is not an accessory to policy but a mechanism for legitimacy, insight, and resilience when enforcement alone cannot secure cooperation. Canada does not need to remake global health on its own. But it does need to decide whether it will help define how cooperation works in a world where rules are weaker, or accept a system in which legitimacy is an afterthought rather than a design principle. In a post-rules-based order, that choice will shape not only Canada’s influence, but whose lives global health governance is ultimately built to protect.

© OpenCanada