BACKGROUND: Non-communicable diseases are a rapidly growing cause of mortality and morbidity in Peru, accounting for 73% of total deaths. There is limited research on health system readiness to manage this rising burden. Our study characterized the readiness of healthcare facilities to manage patients with hypertension and/or type 2 diabetes (T2D) across two public healthcare systems in Puno, a largely rural and low-income department in Peru. METHODS: We adapted the World Health Organization Service Availability and Readiness Assessment to characterize resources and services for hypertension and T2D care. We administered the survey to personnel at healthcare facilities in Puno. Service readiness scores were calculated based on tracer items necessary for hypertension or T2D care. Facilities with ≥ 70% of tracer items were considered ready to manage each disease. RESULTS: Between June 2022 and June 2023, we surveyed 85% (414/488) of Puno's government-run healthcare facilities. Overall, only 28% and 29% were considered ready to manage hypertension and T2D, respectively. Despite larger annual cumulative case volumes at health posts and low-level health centers, lower-level facilities were significantly less likely to be ready to manage hypertension (OR = 0.20, 95% CI 0.11-0.36) or T2D (OR = 0.03, 95% CI 0.01-0.06). Areas of concern included an overreliance on aneroid blood pressure monitors, their infrequent calibration, and limited hemoglobin A1c and urine testing. Additionally, only 66% and 48% of providers self-reported that they could diagnose hypertension and T2D, respectively. There was also low essential medication availability including insulin (7.2%) and fixed-dose combinations (0.5%) and a scarcity of trained healthcare professionals, particularly community health workers at health posts (49.8% had none). CONCLUSIONS: Healthcare facilities were largely unprepared to manage hypertension and T2D, underscoring the critical need for health system strengthening to address disparities in non-communicable disease management across Puno.