This paper uses a gender lens to analyse health system failure in Tanzania in relation to maternal health. Based on an extensive review of literature and data sources, the paper documents the scale of the crisis represented by high and even rising maternal death rates in many low income countries including Tanzania. The paper examines key factors blocking life-saving maternity care in low income countries, showing that hospital care is one major key to tackling the crisis via competent and timely emergency obstetric intervention (EmOC). Particular attention is paid to an often forgotten key driver of gendered inequality in access to health care – health system commercialisation, i.e. a process by which health care provision has become a fee-based service unaffordable by the poor. The paper traces a mutually reinforcing set of factors blocking access to quality life saving maternity care, arguing that taken together they represent a profoundly gender-discriminatory health system structure and health policy history. The paper concludes by calling for recognition of health systems as social institutions in need of sustainable redistributive reforms that greatly lessen gender disadvantage.