In American Indian terms, “survival” (or the more frequently cited Derridean term “survivance,” commandeered by Anishinaabe writer and critic Gerald Vizenor to denote active tribal presencing) implies a willed immunity to the geographical, political, and economic coordinates that define the settler state and overwrite tribal precedence. Such invocations of sovereignty function mainly as intellectual or artistic aspirations rather than lived conditions. The bracing distinctiveness of the South is its magnification of racial separatism and intersectionality all at once – a clash that further highlights the anomalous position of the Indian, banished strategically from an intimate biracial order, and yet locked permanently and in fact produced within those genealogies. Put another way, the primal site of the US plantation, and with it the birth of racial capitalism in the American context, fundamentally relies on the irrelevance and erasure of Indians – and yet it continues to implicate, resurrect, indict, and appropriate their substance at nearly every turn, making them an indelible (if functionally illegible) component of a racialized economy. As a result, “Indians” are simply everywhere and nowhere in the southern narrative.

Health services in most European countries were developed to meet the needs of demand-led health care. Although they still focus mostly on treatment, cure and care (Beaglehole & Dal Poz, 2003), the growing burden of noncommunicable diseases, along with newly emerging communicable diseases and increasing antimicrobial resistance, create strong and shifting demands on these services. At the same time, the growing prevalence of multimorbidity and the widening health inequalities pose additional threats to health systems that do not give enough attention to the factors that produce health. To address these challenges, it is necessary to reorient health services towards more preventive, people-centred and community-based approaches, with a more prominent role for disease prevention and health promotion, integrated within the wider health system.

Worldwide, countries are seeking strategies to strengthen their health workforce to ensure health systems are sustainable and resilient and to reach universal health coverage (World Health Organization, 2016). In Europe, a 2019 expert opinion focused on task shifting, which is one – among several – examples of skill-mix innovations (European Commission, 2019). However, to date, a systematic analysis of skill-mix innovations and their effects on outcomes has been missing. Skill-mix changes have been suggested to be of high relevance to respond to changing patient needs (for example, for patients with chronic conditions and multimorbidity), unequal access to services (for example, for vulnerable groups), skill gaps (for example, in long-term and palliative care) and changes among the health workforce (shortages and maldistribution) (see Chapter 1).

This chapter analyses the role of policies and financing and their implications for the uptake of skill-mix changes in routine care. In particular, it addresses if and how regulatory or nonregulatory policies can facilitate the skill-mix innovation shift (and so act as a facilitator) or rather hinder the shift from taking place (and so act as a barrier). Further, this chapter addresses the role of financing and payment policies and identifies related common barriers and facilitators to skill-mix reforms. The chapter first presents the evidence from the overview of reviews, and then complements these findings by presenting trends and country examples from different sources.

Access to and the quality of health services are closely linked to the density and skill-mix of a country’s health workforce (OECD, 2016; World Health Organization, 2006, 2016). High rates of chronic conditions and multimorbidity, new treatment options, and technological advances and economic pressure have led to fundamental changes to health systems and have impacted on the daily work of health professionals. Many countries worldwide are experiencing a shortage of primary care providers, particularly in rural or socially deprived urban areas (OECD, 2016; World Health Organization, 2013). Primary care systems face the challenge of ensuring a sustainable workforce to allow timely access to services, high-quality care and person-centred services (Kringos et al., 2015a, 2015b).