From natural data, with noise or fractal functions, or modelling natural processes.
PeterSmith Is there a shader that works off 2d or 3d texture to color a pixel based on slope-altitude-uv?
Yes. That's done in the vertex stage. Altitude is available directly from the height map texture, slope via lookup of neighbours needed to calculate the slope.
PeterSmith Do you get 3d artists to hand paint textures?
Nope. Can't pay them ... but there's a plethora of free textures also for PBR workflows on the internet.
Texture splatting or procedural colouring are ways to clad height maps. But height maps aren't the only way to model terrain. They do the visible surface without cavities or too steep slopes.