This study explores the role of domestic politics in China’s health-related development assistance to Africa. It identifies domestic politics as a constant, even critical, component in shaping and structuring China’s health aid to Africa. Until the late 1970s, foreign policy considerations determined the volume, direction and terms of China’s foreign aid, but since the 1980s domestic political economy has dominated China’s health aid policy process. China today utilises development assistance for health not only to expand its global influence and improve its international image, but also to serve the market and resource needs of its domestic economic development. An examination of existing policy-making and implementation regimes in health aid highlights the role of bureaucratic politics and other political-institutional variables in affecting the form, substance and effectiveness of foreign aid to Africa. The findings have important implications in China’s willingness and capacity to cooperate with the global donor community in Africa.