Measures of personal satisfaction with health systems play an increasingly important role in national and international performance assessments. Using data from the 2010 Commonwealth Fund International Health Policy Survey, we analyzed the determinants of personal perceptions of health system performance in eleven high-income countries. In most countries there was a clear relationship between overall satisfaction with the health system and perceptions of affordability and effectiveness of care, as well as ratings of one's regular doctor. There is some evidence that waiting times for appointments and diagnosis were widely associated with discontent, although respondents' perceptions of these factors explained relatively little of the observed variation in overall satisfaction across countries. We conclude that "satisfaction" appears to represent something different in each health system, and that policy makers can nevertheless use this type of analysis to determine priorities for improvement in their own country. Our findings also indicate that some of the keys to improving overall satisfaction with a health system may lie outside that system's direct control and are related to differences in expectations across countries and to other factors that influence perceptions, such as national political debates, reporting in the news media, and national cultures.