Background: Since 2015, the CDC has supported the development and implementation of healthcare-associated infection (HAI) surveillance in resource-limited settings through technical support of case definitions and methods that are feasible with existing surveillance capacity and integration with clinical care to maximize sustainability and data use for action. Methods: Surveillance initiatives included facility-level implementation programs in Kenya, Sierra Leone, Thailand, and Georgia; larger national or regional network-level projects in India and Vietnam were also supported. For assessment and planning, surveillance capacities were grouped into 3 domains: staff, informatics, and diagnostic capacities. Based on these capacities, simplified case definitions surveillance methodologies were devised to balance resources and effort with the anticipated value and use of findings. Results: There was broad understanding of the importance of HAI surveillance; however, the required resources and other challenges (eg, training, staffing, quality of available data) were underappreciated. Staff capacities were often influenced by a lack of dedicated surveillance staff and limited experience in systematic data collection and analysis. Informatics capacities were generally limited by the lack of digital data management, nonstandardized clinical data collection and storage, and the inability to assign and maintain unique patient identifiers. We found that capacity for diagnostics, a critical component of traditional HAI surveillance systems, was limited by its availability, frequency of use, and inconsistent rationale in clinical care. We found that successful surveillance strategies were generally simple, matched existing capacities, and targeted specific HAI priorities identified by clinical teams. For example, in Kenya and Sierra Leone, participating facilities established, with minimal external support, simplified SSI surveillance among post–caesarean-delivery patients. These initiatives improved integration of surveillance with clinical care through encouraging participation of the clinical team in surveillance and planning. Furthermore, these models directly linked surveillance activities to improved patient care (eg, combined clinical checklists with surveillance data collection forms). Discussion: In resource-limited settings, the local cost and effort required to establish and sustain the necessary infrastructure for HAI surveillance can be substantial. Establishing actionable and sustainable HAI surveillance can be achieved through simplifying HAI surveillance to match existing capacities and can result in valuable surveillance programs, even in very resource-limited settings.