The COVID-19 pandemic continues to challenge healthcare systems globally. To understand hospital capacity, including critical oxygen capacity, a pragmatic assessment of all public hospitals in Lesotho was made in July 2020 (baseline), with follow-up in December 2020. We developed a qualitative hospital services questionnaire modeled on the World Health Organization COVID-19 assessment tool and converted answers into quantitative ordinal variables. At baseline we found all 12 domains had areas demonstrating preparedness and weakness. Key baseline gaps within infection prevention and control were lack of a dedicated team, and insufficient personal protective equipment and space for donning and doffing. Substantial limitations were noted in hypoxemia diagnosis and treatment; information management and care coordination pathways were also suboptimal. Our baseline findings may reflect uneven early pandemic care quality. Targeted follow-up after five months revealed marked improvement in the availability of pulse oximetry, oxygen capacity, and heated high flow nasal cannula devices.