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........

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