Articles 49 TFEU and 56 TFEU must be interpreted as meaning that they do not preclude national legislation which allows local authorities to entrust the provision of medical transport services by direct award, without any form of advertising, to voluntary associations, provided that the legal and contractual framework in which the activity of those associations is carried out actually contributes to the social purpose and the pursuit of the objectives of the good of the community and budgetary efficiency.

The award, in the absence of any transparency, of a contract to an undertaking located in the same Member State as the contracting authority amounts to a difference in treatment to the detriment of undertakings which might be interested in that contract but are established in another Member State. Unless it is justified by objective circumstances, such a difference in treatment, which, by excluding all undertakings established in another Member State, would operate mainly to the detriment of the latter undertakings, would amount to indirect discrimination on the basis of nationality, prohibited under Articles 49 TFEU and 56 TFEU.

However, the Member States have the power to organise their public health and social security systems. Furthermore, not only the risk of seriously undermining the financial balance of a social security system may constitute, per se, an overriding reason in the general interest capable of justifying an obstacle to the freedom to provide services, but also the objective of maintaining, on grounds of public health, a balanced medical and hospital service open to all may also fall within one of the derogations on grounds of public health, in so far as it contributes to the attainment of a high level of health protection. Thus, measures which aim, first, to meet the objective of guaranteeing in the territory of the Member State concerned sufficient and permanent access to a balanced range of high-quality medical treatment and, secondly, assist in ensuring the desired control of costs and prevention, as far as possible, of any wastage of financial, technical and human resources are also covered.

In that regard, a Member State, in the context of its discretion to decide the level of protection of public health and to organise its social security system, may take the view that recourse to voluntary associations is consistent with the social purpose of the ambulance services and may help to control costs relating to those services. It is essential that, where they act in that context, the voluntary associations do not pursue objectives other than those cited above, do not make any profit as a result of their services, apart from the reimbursement of the variable, fixed and on-going expenditure necessary to provide them, and do not procure any profit for their members.

It is for the national court to carry out all the assessments required in order to verify whether the contract and, where relevant, the framework agreement, as regulated by the applicable legislation, actually contribute to the social purpose and the pursuit of the objectives of the good of the community and budgetary efficiency.

(see paras 56, 61, 62, 64, 66, 67, operative part 1)